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FASTING  AND  UNDERNUTRITION 

IN  THE 

TREATMENT  OF  DIABETES 


BY 

HEINRICH   STERN,   M.D,   LL.D. 

VISITING  PHYSICIAN,  ST.  MARK'S  HOSPITAL;  CONSULTING  PHYSICIAN,  METHODIST- 
EPISCOPAL      (SENEY)       HOSPITAL;      STATE     HOSPITAL     AT     CENTRAL     ISLIP; 
DEACONESSES'     HOME;     PORT    CHESTER    AND   GLENS    FALLS    HOSPITALS; 
FOUNDER  AND  EDITOR  OF  THE  ARCHIVES  OF  DIAGNOSIS;    FORMERLY 
CHAIRMAN,  SECTION  ON  PHARMACOLOGY   AND  MATERIA  MEDICA, 
AMERICAN    MEDICAL    ASSOCIATION;     PRESIDENT     NEW    YORK 
PHYSICIANS'    ASSOCIATION;    FELLOW    OF    THE   AMERICAN 
CONGRESS    ON    INTERNAL    MEDICINE;    THE    AMERICAN 
UROLOGICAL  ASSOCIATION;  THE  AMERICAN  THERA- 
PEUTIC   society;    THE    NEW    YORK   ACADEMY 
OF  MEDICINE.    ETC..    ETC. 


MEDICAL    A] 

(FORMERLY   REB.N 

NEW  YOWK 

30  IRVING    PLACE  (cor.   e.    ,6th  st.) 
TEL.   CALEDONIA   3012 


COPYHIGHT,    1916,    BT 

REBMAN    COMPANY 
New  York 


PRINTED  VS  AMERICA 


PREFACE  , 

Fasting  {not  starvation)  has  an  assured  place 
in  diabetes  therapy,  a  place,  however,  which  is 
not  by  far  as  important  as  some  modern  en- 
thusiasts are  wont  to  make  us  believe.  Fasting 
without  being  followed  by  undernutrition  is  en- 
tirely valueless  so  far  as  the  management  of 
diabetes  is  concerned. 

In  the  preponderating  majority  of  instances  of 
diabetes  a  protracted  fasting-undernutrition  regi- 
men is,  fortunately,  not  indicated.  In  all  such 
cases  we  do  more  lasting  good  without  incurring 
any  risks  by  following  the  older  approved  meth- 
ods of  dieting. 

Only  the  advanced  and  severest  forms  of  dia- 
betes which  are  no  longer  or  never  were  bene- 
ficially influenced  by  ordinary  antidiabetic  dieting 
are  apt  to  be  appreciably  improved  by  continued 
fasting  and  undernutrition. 

This  little  book  is  based  entirely  upon  personal 
observations  and  experiences.  It  mil  be  found 
that  it  differs,  in  certain  essentials  and  in  a  num- 
ber of  details,  from  the  rules  and  regulations  laid 

v 


vi  Pkeface 

down  by  others  in  articles  dealing  with  the  same 
theme.  The  discussion  of  hypothetical  subjects 
has  been  avoided  in  the  main  text  (Part  I).  A 
few  more  or  less  theoretical  points,  particularly 
the  question  of  the  ketones,  have  been  dwelled 
upon  at  greater  length  in  Part  II,  the  supple- 
mentary portion  of  the  book. 

Heinrich  Stern, 
New  York. 


CONTENTS 


FACS 


I.  Introductory  Remarks  3 

II.  Technic    of    Therapeutic   Fasting   in    Dia- 


betes 


11 


III.  Breaking  of  the  Fast  and  Undernutrition 

IN  Diabetes 26 

IV.  Failures • 48 

V.  Physico-Therapeutic  Measures  in  the  Man- 
agement of  Severe  Forms  of  Diabetes    56 

YI.  Illustrative  Cases  64 

Supplementary  Notes  on  the  Topic  of  the 
Ketones  in  the  Human  Organism 

I.  The  Acetone  Bodies  in  the  Urine  and  the 

Ferric  Chlorid  Reaction  97 

II.  Are  there  Ketones  of  Intestinal  Produc- 
tion!       101 

III.  Concerning  the  Suppression  of  the  Ace- 

tone Bodies  in  Diabetics Ill 

IV.  The  ''Yolk  Cure"  in  the  Treatment  of  the 

Underfed 133 

V.  The  Fat  Question  in  Its  Relation  to  the 
Production  and  Cure  of  Infantile  Ma- 
rasmas 147 

Assay  of  the  Urine 1*71 

Estimation  of  Sugar  in  the  Blood *190 

Nutritive  Constituents  of  Food 195-213 

Index 215 

vii 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Gommons 


http://www.archive.org/details/fastingundernutrOOster 


PART    I 


FASTING    AND     UNDERNUTRITION 

IN   THE   TREATMENT   OF 

DIABETES 


Introductory  Remarks 

There  is  no  pathological  condition  in  the  clini- 
cal control  of  which  dietary  treatment  plays  such 
a  paramount  influence  as  in  diabetes  mellitus. 
There  is  no  other  agent  except  a  proper  regula- 
tion of  the  diet  that  has  ever  been  of  any  real 
value  in  reducing  the  two  cardinal  symptoms  of 
diabetes:  weakness  and  glycosuria.  This  fact 
has  been  definitely  recognized  ever  since  the  ad- 
vent of  the  physiological  school  of  medicine. 

Diabetes  is  and  remains  a  wasting  disease.  By 
a  rational  system  of  dieting  adapted  to  the  in- 
dividual case  and  to  each  period  in  the  course 
of  the  affection,  the  painstaking  clinician  is  often 
enabled  to  stem  its  progress — or  rather  its  rapid 
progress — for  the  time  being.  This  dietary  indi- 
vidualization consists  of  the  periodical  diminu- 
tion or  the  temporary  withdrawal  of  one  or  all 
the  types  of  nutriments. 

The  almost  universal  tonic  for  the  confirmed 

3 


4  Fasting  and  Undernutrition  in 

diabetic  is  the  permanent,  or  almost  permanent, 
complete  withdrawal  of  all  the  sugar-containing 
aliments,  and  the  greater  or  lesser  temporary 
reduction  of  starchy  foods.  Upon  this  plan  of 
withholding  and  decrease  the  management  of  the 
average  case  of  diabetes  has  been  based  since  the 
times  of  Pavy,  Kiilz,  Bouchardat,  Ebsteiu  and 
Naunyn. 

There  are  numerous  modifications  of  the  sugar- 
free  and  starch-poor  regimen.  In  the  end  all 
pertaining  restrictions  and  modifications  amount 
to  the  same  thing :  to  render  the  patient  stronger 
and  more  resistant,  and  sugar-free. 

A  logical  outcome  of  Chittenden's  ** Physiologi- 
cal Economy  in  Nutrition,"  published  in  1904, 
was  that  about  two  or  three  years  later  the  pro- 
teins, especially  those  derived  from  meats,  were 
also  to  a  certain  extent  withheld  from  the  dia- 
betic. Finally  a  few  clinicians  decided  that  the 
reduction  of  all  the  types  of  nutriments  was  the 
sine  qua  non  in  the  treatment  of  diabetes.  While 
it  was  the  accepted  dictum  before  the  investiga- 
tions of  Chittenden  that  the  diabetic  should  be 
maintained  in  a  rather  continuous  state  of  over- 
nutrition,  a  doctrine  has  lately  been  promulgated 
according  to  which  the  life  of  the  diabetic  should 
be  one  of  everlasting  renunciation  and  undernu- 
trition. The  first  therapeutic  conception  is  based 
on  the  assumption  that  diabetes  is  a  wasting  dis- 
ease; the  latter  conception  on  the  observation 
that  a  few  diabetics  get  along  better  and  become 


The  Treatment  of  Diabetes  5 

more  active  after  they  have  lost  ten,  twenty  or 
more  pounds. 

On  the  face  of  it,  however,  the  treatment  of. 
the  average  case  of  diabetes  by  a  system  of  con- 
tinuous undernutrition  bears  the  stamp  of  inex- 
perience, irrationality  and  harmfulness.  Such  a 
plan  of  treatment  has  its  place  in  a  small  pro- 
portion of  the  cases  of  diabetes,  in  such  cases  in 
which  besides  a  persistent  glycosuria,  a  pro- 
nounced and  obstinate  ketonosis  (acidosis)  and 
rapid  decline  of  body-weight  and  strength  are 
present. 

Here,  it  is  true,  fasting  and  undernutrition 
may  produce  wonders;  in  the  preponderating 
majority  of  instances  of  diabetes,  however,  the 
patient  vrill  get  along  much  better,  and  is  apt  to 
remain  a  useful  member  of  society  for  a  number 
of  years  if  he  be  not  kept  below  par. 

On  the  other  hand,  forced  feeding  in  diabetes 
is  not  always  devoid  of  danger.  Instead  of  as- 
sisting in  the  adjustment  of  the  activity  of  the 
liver,  continued  overalimentation  is  bound  to 
diminish  and  undermine,  sooner  or  later,  the 
function  of  this  most  important  organ  of  the 
human  body.  Again,  a  liver  that  is  not  func- 
tionating perfectly  can  neither  prevent  the  ali- 
mentary poisons  from  entering  into  the  general 
blood  stream,  nor  is  it  able  to  cause  normal  cleav- 
age of  the  intermediary  products  of  metabolism. 

That  total  abstinence  from  food  for  from  three 
to  four  successive  days  renders  the  urine  of  the 


6  Fasting  and  Undernutrition  in 

patient  with  severe  diabetes  sugar-free  and  **dis- 
intoxicates''  the  diabetic  organism,  was  the  im- 
portant observation  of  G.  Guelpa,  of  Paris.  This 
clinical  discovery  has  proved  of  great  moment 
in  the  management  of  both  (1)  the  grave  types 
of  diabetes,  and  (2)  the  overnonrished  cases  of 
diabetes  in  which  the  liver  no  longer  affords  the 
necessary  protection  against  the  various  forms 
of  autointoxication.  "While  it  is  true  that  the 
discoverer's  own  hypotheses  respecting  the  ra- 
tionale of  the  fasting  treatment  of  diabetes  are 
to  the  greater  part  scientifically  untenable,  it  is 
nevertheless  Guelpa  who  has  shown  us  a  way 
out  of  the  bewildering  vagaries  of  diabetes  ther- 
apy. We  should  never  forget  that  it  was  this 
French  clinician  who  first  in  all  the  world  de- 
clared that  all  food  may  be  withheld  for  a  number 
of  days  from  a  human  diabetic  without  inciting 
ketonosis  (acidosis)  and  subsequent  coma.  By 
one  leap  the  treatment  of  severe  diabetes  has 
suddenly  made  more  progress  than  it  has  for  the 
previous  quarter  of  a  century. 

Guelpa 's  "cure  by  privation"  (abstinence 
from  food  and  purgation)  consists  of  the  fol- 
lowing :* 

First.    The  taking  every  day  for  two,  three  or 

•Guelpa:  Starvation  and  Purgation  in  the  Relief  of  Disease. 
Brit.  Med.  Ass.,  July,  1910.  Published  in  Brit.  Med.  Jour.,  Oct. 
8,  1910.  Guelpa:  Autointoxication  and  Disintoxication.  Trans- 
lated by  F.  S.  Arnold,  B.A.,  M.B.,  B.Ch.  (Oxon.),  New  York, 
Rebman  Company. 


The  Treatment  of  Diabetes  7 

four  days  of  a  bottle  of  Himyadi  Janos  water, 
warmed  if  possible,  or  from  40  to  55  c.c.  (mils)  = 
one  and  one-quarter  to  one  and  three-quarters 
oimces  of  castor  oil,  followed  by  about  750  c.c. 
(mils)  =  one  pint  and  a  half — of  water. 

Second.  The  abstinence  during  this  period  of 
all  kinds  of  food. 

Third.  The  free  imbibing  of  water  (not  car- 
bonated), weak  tea  without  milk,  toast  and  water, 
fruit  infusion,  etc.  (Up  to  the  time  of  the  publi- 
cation of  the  translation  of  his  book,  Guelpa  had 
avoided  any  drug  treatment  whatever,  as  he 
wished  to  prevent  any  self-deception  concerning 
the  therapeutic  influence  of  the  treatment.) 

Guelpa  declares  that  it  is  only  rarely  that  a 
patient  has  difficulty  in  completing  his  three  or 
more  days'  fast.  This  he  finds  especially  true 
if  the  purge  and  the  other  liquids  that  are  im- 
bibed during  the  fasting  period  are  taken  warm. 
The  method  of  treatment  usually  calls  forth  pro- 
nounced improvement  in  the  patient's  state  of 
health.  In  no  instance  had  any  aggravation  of 
the  disease  resulted  on  account  of  the  fasting  and 
purging. 

The  benefits  accruing  from  this  plan  of  treat- 
ment are,  according  to  Guelpa,  the  follomng: 

First.  Total  disappearance  of  the  annoying 
and  distressing  sensation  of  hunger. 

Second.  Marked  decrease  of  the  intestinal 
bacteria,  and  therefore  a  pretty  perfect  state  of 
disinfection  of  the  intestinal  tract. 

Third,    Pronounced  reduction  of  thirst. 


8  Fasting  and  Undernutrition  in 

Fourth.  Suppression  or  conspicuous  decline 
of  perspiration,  even  in  the  heat  of  summer. 

Fifth.  Production  of  normal,  periodic  sleep, 
very  refreshing  though  somewhat  shortened  in 
length.  The  patient,  awakening  passes  through 
no  stage  of  drowsiness;  full  mental  activity  en- 
suing immediately. 

Sixth.  Firmness  of  the  pulse  and  diminution 
of  blood  pressure,  and  increase  in  hemoglobin, 
red  cells  and  leukocytes. 

Seventh.  A  decrease  in  the  volume  of  certain 
visceral  organs,  particularly  the  heart  and  liver, 
with  greater  and  easier  lung  expansion. 

Eighth.  Continuous  loss  in  body  weight,  at 
the  average  rate  of  two  pounds  a  day.  Concur- 
ring therewith  the  activity  of  the  heart  and  other 
organs  becomes  less  oppressed. 

Ninth.  Disappearance  of  joint  and  muscular 
pains  and  the  production  of  a  feeling  of  agility, 
liveliness  and  well-being. 

Excepting  a  few  loose  statements  concerning  a 
low  protein  intake,  Guelpa  has  not  devoted  much 
attention  to  the  dietary  treatment  follotving  the 
fasting  periods.  More  or  less  he  has  concentrated 
his  therapeutic  endeavors  upon  that  what  is  now 
understood  as  the  *  initial  fast,''  and  has  given 
no  or  but  scant  rules  how  to  proceed  as  regards 
the  food-intake  after  the  fasting  period  is  broken. 
Yet  the  question  how  to  go  ahead  after  the  fast- 
ing days  without  occasioning  the  reoccurrence  of 


The  Treatment  of  Diabetes  9 

sugar  and  ketones  is  the  only  intricate  one  con- 
nected with  the  plan  of  treatment.  The  fasting 
period  itself  offers  no  difficulty  whatever. 

Fasting  and  undernutrition  in  the  treatment 
of  diabetes  must  never  assume  a  stereotyped 
character.  Some  patients  do  well  on  a  one  or  two 
days'  fast  and  a  week  of  undernutrition;  in 
others  the  fasting  period  should  extend  over  five, 
six  or  more  days,  and  the  subsequent  undernu- 
trition should  be  continued  for  one,  two,  three  or 
more  months.  In  some  diabetics  of  the  graver 
types  a  fast  day  weekly  or  fortnightly  and  a 
slight  reduction  of  the  diet  may  keep  the  disease 
in  check,  in  others  the  duration  of  the  periodical 
fasting  term  and  a  much  more  decided  reduction 
of  alimentation  are  necessary  to  accomplish  the 
desired  end. 

Fasting  with  subsequent  undernutrition  must 
go  hand  in  hand  in  the  treatment  of  the  severe 
forms  of  diabetes.  This  fact  was  already  recog- 
nized in  some  degree  by  Naunyn  when  he  advo- 
cated the  interpolation  of  ** green  days"  in  the 
dietary  of  the  patient  affected  with  grave  or  ad- 
vanced diabetes.  These  ** green  days,"  however, 
are  to  all  intents  and  purposes  fast  days,  as  the 
patient  obtains  on  them  but  a  certain  amount  of 
green  vegetables  whose  low  starch  content  is  not 
readily  attacked  by  the  digestive  juices. 

Undernutrition  in  diabetes,  as  I  understand 
and  uphold  it,  is  not  the  reduction  of  the  intake 
of  one  class  of  foodstuffs,  but  of  all  of  them.    The 


10  Fasting  and  Undernutrition  in 

proportion  in  the  diminution  of  the  various  arti- 
cles of  food  mnst,  however,  of  necessity  differ  in 
the  various  phases  after  the  fast.  Fats,  particu- 
larly those  of  high  melting  point,  may  practi- 
cally always  be  permitted,  though  they  may  on 
rare  occasions  give  rise  to  a  slight  ketonosis 
(acidosis)  or  aggravate  an  already  existing  one. 
Proteins  of  animal  origin,  in  more  or  less  reduced 
amounts,  must  be  resorted  to  soon  after  the  fast. 
The  patient  simply  cannot  get  along  without 
them,  despite  the  assertions  of  some  clinicians  to 
the  contrary.  Great  care,  however,  must  be  exer- 
cised that  the  ingested  proteins  do  not  over- 
burden the  liver.  The  starches  should  be  added 
latest  and  then  only  in  the  form  of  vegetables 
containing  at  first  not  more  than  five  per  cent, 
of  carbohydrate  matter  which  is  not  readily  elab- 
orated by  intestinal  activity. 

It  is  now  almost  six  years  since  I  started  to 
make  use  of  Guelpa's  method  in  suitable  cases. 
Naturally,  I  have  modified  and  amplified  it  ac- 
cording to  the  needs  of  the  manifold  cases  which 
have  come  under  my  observation  since  that  time. 
The  general  plan  of  treatment  by  fasting  and 
undernutrition,  as  evolved  by  me,  differs  in  more 
than  one  respect  from  similar  endeavors.  This 
plan  of  treatment  which  is  minutely  dwelled  upon 
in  the  following  pages  is  designed  as  a  guide, 
pure  and  simple,  and  as  such  it  merely  points  to 
a  course  of  procedure,  but  it  is  readily  capable 
of  modification  and  adaptation  to  individual 
demands. 


The  Treatment  of  Diabetes  11 


II 

Technic  of  Therapeutic  Fasting  in  Diabetes 

Where  to  take  the  fasts 

AVhile  the  liospital,  on  account  of  its  labora- 
tory and  other  facilities,  may  be  the  best  place 
in  which  to  let  the  patient  take  his  initial  fast, 
the  home,  for  reasons  presently  to  be  explained, 
is  after  all  to  be  preferred  when  the  patient  has 
to  submit  to  frequently  repeated  fasting  periods. 
The  fasts  in  order  to  do  any  good  should  be 
undertaken  at  certain,  preferably  regular  inter- 
vals. One  fast  is  of  little  consequence,  and  it 
should  be  remembered  that  one  swallow  does  not 
make  a  summer. 

The  arguments  in  favor  of  home  treatment 
are,  (1)  the  simplicity  of  the  management  of  the 
case  itself;  (2)  the  simplicity  of  the  necessary 
tests  which,  if  need  be,  may  be  performed  at  the 
bedside  by  the  physician,  a  nurse  or  by  the  pa- 
tient himself;  (3)  the  accustomed  atmosphere 
which  is  much  less  apt  to  depress  the  patient  than 
the  hospital  milieu,  and  (4)  the  inexpensive- 
ness  as  compared  with  the  extravagant  hospital 
charges. 

The  patient  should  be  resting  in  bed  during 
the  entire  course  of  the  fast.  The  room  should 
have  a  southern  exposure,  if  possible,  but  it  must 


12  Fasting  and  Undernutrition  in 

not  be  artificially  heated.  The  toilet,  if  conveni- 
ently located,  may  be  used  by  the  patient.  If  this 
be  not  the  case  a  commode  must  be  employed. 

The  attending  physician 

During  the  inaugural  fasting  period  the  at- 
tending physician  should  make  daily  calls  and 
personally  assure  himself  of  the  patient's  physi- 
cal condition.  He  should  perform  or  should  have 
performed  a  blood  examination  for  glucose  be- 
fore the  fast  is  started.  In  the  beginning  it  is 
well  to  examine  for  blood-sugar  every  third  or 
fourth  day.  This,  however,  is  not  imperative. 
The  urine  should  be  tested  every  day  for  grape- 
sugar  and  the  ketone  substances,  especially  ace- 
tone and  diacetic  acid.  (The  examination  for 
beta-oxybutyric  acid  is  difficult  and  time-consum- 
ing, and  is  by  no  means  essential  in  the  general 
run  of  cases.) 

During  subsequent  fasts — provided  no  compli- 
cations ensue — the  physician  need  not  pay  any 
calls.  He  should,  however,  make  a  daily  urinary 
assay.  If  there  be  any  indication,  an  examina- 
tion for  blood-sugar  should  be  made  at  the  be- 
ginning and  conclusion  of  each  subsequent  fast. 
The  physician  should  give  his  orders  either  to  a 
nurse,  a  member  of  the  family  or  to  the  patient 
himself. 

The  nurse 

The  initial  fasting  period  should  be  under  the 
direct  and  continued  supervision  of  a  nurse.    The 


The  Treatment  of  Diabetes  13 

nurse,  as  a  matter  of  course,  receives  her  instruc- 
tions from  the  attending  physician  to  whom  he 
or  she  should  report  the  patient's  condition  as 
often  as  the  exigencies  of  the  case  demand.  It 
is  the  nurse  who  has  to  minister  to  the  wants  of 
the  patient  and  who  has  to  keep  him  as  comfort- 
able as  possible.  It  is  the  nurse — and  this  should 
be  particularly  the  case  during  the  initial  fast — 
who  forms  besides  the  physician  the  sole  means 
of  communication  between  the  patient  and  the 
outside  world. 

The  nurse  should  keep  a  chart  of  the  tempera- 
ture, pulse  and  respiration  w^hich  should  be  re- 
corded from  three  to  five  times  during  the  twenty- 
four  hours.  The  temperature  should  always  be 
taken  in  the  rectum  unless  a  disease  of  the  same 
precludes  this.  The  condition  of  the  skin  should 
be  recorded,  whether  it  be  warm  or  cold,  dry  or 
moist,  etc.  Besides  an  exact  account,  both  as  to 
the  amount  and  the  time  of  the  intake  of  liquids 
and  the  output  of  urine  and  feces  must  be  kept 
by  the  nurse.  In  subsequent  fasts,  when  the  dia- 
betic state  of  the  patient  is  no  longer  an  unknown 
factor  to  the  medical  observer,  it  is  not  essential 
that  a  detailed  chart  be  kept  in  the  average  case. 

The  nurse  need  not  belong  to  the  privileged 
** registered"  class.  Any  member  of  the  family 
with  a  little  common  sense,  possessing  some  tact 
and  devotion,  is  able  to  nurse  an  uncomplicated 
case  of  the  graver  forms  of  diabetes  during  all 
but  the  initial  fasts.    Many  servants  who  watch 


14  Fasting  and  Undernutrition  in 

the  doings  of  the  trained  attendant  during  the 
initial  fasting  period  will  make  excellent  nurses 
for  cases  during  the  periods  of  fasting  and  under- 
nutrition. Indeed,  my  best  nurses  for  patients 
suffering  from  nutritive  disturbances  I  have  re- 
cruited from  the  ranks  of  the  ** unregistered," 
the  common  garden  and  field  variety  of  attend- 
ants. Last  but  not  least,  they  receive  only  from 
one-third  to  one-half  the  salary  which  the  **E.  N.'' 
exacts. 

The  patient  his  own  nurse 

I  am  often  asked  by  the  patient  why  he  cannot 
act  as  his  own  nurse  during  the  therapeutic  fasts. 
Excepting,  of  course,  the  initial  fast  when  valu- 
able data  for  the  future  guidance  of  his  case  are 
to  be  gained  and  when  he  is  necessarily  to  be 
kept  under  close  medical  surveillance,  the  ques- 
tion is  certainly  justified  as,  roughly  speaking, 
about  half  of  the  cases  get  along  quite  nicely 
without  any  special  assistance.  It  is  my  experi- 
ence that  male  diabetics  may  be  more  trusted  in 
this  respect  than  their  female  fellow-suiferers. 
As  a  rule,  the  members  of  the  stronger  sex  have 
a  much  better  conception  of  their  disease  than 
those  of  the  weaker  one,  and  men  have  a  much 
keener  appreciation  than  women  of  the  necessity 
that  something  be  done  for  their  infirmity.  Of 
course,  when  entirely  without  the  help  of  some- 
body the  diabetic  patient  cannot  keep  his  fast. 
Someone  has  to  make  his  bed,  prepare  the  per- 


The  Treatment  of  Diabetes  15 

mitted  liquids  for  him,  and  do  other  chores.  How- 
ever, as  just  stated,  about  one-half  of  the  cases 
need  no  special  attendance  whatever. 

The  patient  himself 

It  goes  without  saying  that  the  patient  must 
have  full  confidence  in  his  physician.  He  should 
talk  matters  over  with  him,  and  not  start  fasting 
unless  he  feels  assured  that  this  therapeutic  meas- 
ure is  going  to  benefit  his  condition.  The  patient 
should  become  acquainted  with  the  fact  that  the 
fast  is  to  be  immediately  followed  by  a  more  or 
less  protracted  period  of  undernutrition.  He 
must  foster  a  certain  degree  of  self-denial  and  as- 
sume a  mental  attitude  of  submission,  good  will 
and  trust.  He  must  be  entirely  free  from  mental 
unrest,  and  for  this  reason  should  put  his  house 
in  order  before  he  attempts  the  fasts.  He  must 
not  question  the  orders  of  his  physician  once  the 
fast  has  begun.  Worry,  exaltation  and  excite- 
ment are  only  too  apt  to  aggravate  a  case  of  dia- 
betes and  to  increase  the  intensity  of  the  sugar 
excretion. 

The  patient  mil  note  that  when  the  ice  is  once 
broken,  viz.,  after  he  has  undergone  the  initial 
fast,  that  there  are  worse  things  than  abstaining 
from  food  for  a  number  of  days.  In  subsequent 
fasts  many  patients  are  masters  of  the  situation, 
indeed  so  much  so  that  everything  connected  with 
the  therapeutic  fasts,  even  the  slightest  detail, 
may  be  left  to  their  o^\m  discretion  and  execution. 


16  Fastifg  and  Undernutrition  in 

The  cooperation  of  such  patients  with  their  phy- 
sicians spells  success — if  a  favorable  issue  can  be 
obtained  by  this  plan  of  treatment. 

Duration  of  the  fast 

The  average  ketonemic  diabetic  voids  a  sugar 
and  acetone-free  urine  in  from  three  to  five  days 
after  starting  the  initial  fast.  A  majority  of 
these  patients  cease  to  excrete  sugar  within 
forty-eight  or  sixty  hours.  In  some  patients  the 
glycosuric  symptom  already  terminates  after  the 
omission  of  two  or  three  meals ;  in  others  it  per- 
sists for  six  days  or  even  longer.  Again,  there 
are  cases  of  the  severest  type  of  diabetes  which 
no  amount  of  fasting  will  render  sugar-free. 
Generally  speaking,  the  initial  fast  should  not 
come  to  an  end  when  sugar  ceases  to  be  excreted, 
but  should  be  continued  for  another  twenty-four 
or  forty-eight  hours. 

It  always  takes  longer  to  render  the  patient  ^s 
urine  free  from  ketones  (diacetic  acid,  acetone, 
beta-oxybutyric  acid,  etc.)  than  from  sugar.  In 
a  rather  considerable  number  of  instances — 
twenty-five  per  cent,  approximately — ^no  amount 
of  fasting  will  accomplish  this  feat.  In  these 
cases  prolonged  starvation  treatment  is  out  of 
place ;  the  accustomed  diet  should  be  taken  up  as 
soon  as  possible. 

Subsequent  fasts  need  hardly  ever  be  pro- 
tracted unless  the  intervening  period  has  been  an 
exceptionally  long  one.     The  intercalation  of  a 


The  Treatment  of  Diabetes  17 

hunger-day,  as  advocated  by  former  authors,  will 
often  suffice. 

Frequency  of  the  fast 

No  iron-clad  rules  concerning  the  frequency  of 
the  therapeutic  fasts  can  be  propounded.  Once 
the  inaugural  fast  is  over  and  the  severity  of  the 
case  determined  {i.e.,  the  readiness  of  the  disap- 
pearance and  reappearance  of  the  urinary  sugar 
and  ketones),. it  is  a  simple  matter  to  decide  when 
and  how  often  subsequent  fasts  should  be  under- 
taken. The  decision  resolves  itself  in  the  an- 
swering of  the  following  two  questions:  Firstly, 
has  the  inaugural  fast  been  of  benefit  to  the  pa- 
tient; secondly,  is  the  patient  to  be  kept  entirely 
sugar-  and  acetone-free  during  the  interval. 

It  should  be  the  physician's  endeavor  not  only 
to  prolong  life,  but  also  to  prolong  the  usefulness 
of  his  patient.  For  years  I  have  advocated  that 
the  diabetic  with  low  carbohydrate  tolerance  and 
a  tendency  to  acetonuria  should  make  a  fast-day 
of  that  which  is  euphoniously  called  ^^the  day  of 
rest."  If  possible,  I  let  him  also  add  the  Satur- 
day half-holiday.  By  cutting  out  the  Saturday 
mid-day  meal  and  permitting  a  very  moderate 
supper  on  Sunday,  a  fasting  period  of  about 
thirty  hours  is  obtained  without  interfering  ^^dth 
the  patient's  business.  I  am  in  the  habit  of  al- 
lowing a  small  amount  of  food  on  Sunday  evening 
in  order  that  the  patient  is  able  to  resume  work 
the  next  morning,  which  he  does  after  taking  his 


18  Fasting  and  Undernutrition  in 

regular  breakfast.  These  weekly  fasts  are  a 
great  boon  to  the  average  patient  affected  with  a 
severe  type  of  diabetes,  and  often  enable  him  to- 
gether with  the  restricted  diet  during  the  week 
to  keep  above  water  in  a  physical,  financial  and 
social  sense. 

In  many  cases  a  one-day  fast  every  second  or 
third  week  may  suffice,  in  others  of  the  sev- 
erer and  severest  types  more  protracted  fasting 
periods — for  from  two  to  four  days — should  be 
instituted  every  two  weeks.  Thus  it  may  be 
necessary  that  four  days  out  of  every  fourteen 
must  be  spent  fasting.  It  should  not  be  forgot- 
ten, however,  that  a  certain  proportion  of  these 
cases  are  not  only  not  benefited  but  actually 
harmed  by  this  treatment.  The  initial  fast  en- 
ables the  clinician  to  recognize  the  cases  not 
suited  for  the  fasting-undernutrition  treatment. 

The  indications  for  instituting  protracted  fast- 
ing periods  other  than  the  initial  one,  are:  pro- 
gressive weakness  of  the  patient,  certain  com- 
plications like  gangrene  and  infection,  very  low 
or  negative  carbohydrate  tolerance,  pronounced 
ketonosis  (acetonuria,  acidosis,  etc.),  heart  dis- 
ease (fat  heart),  marked  obesity  and  disease  of 
the  liver  (hepatic  inefficiency)  and  kidneys  (renal 
insufficiency). 

All  subsequent  protracted  fasting  must  occur 
while  the  patient  is  resting  in  bed  and  under  the 
same  general  conditions  as  the  inaugural  fast.  A 
single  weekly  fast-day,  however,  does  not  call  for 


The  Treatment  of  Diabetes  19 

bed-rest,  especially  not  in  summer  time.  The  pa- 
tient may  spend  the  day  in  the  open  air,  reclining 
in  a  steamer  chair  or  other  comfortable  piece  of 
furniture,  but  away  from  the  hustle  and  bustle 
of  every-day  life. 

Other  essentials  in  therapeutic  fasting 

A.  Purging. — Inasmuch  as  fasting  in  the  graver 
forms  of  diabetes  is  considered  by  Guelpa  to  be 
a  method  of  disintoxication,  he  combines  the 
treatment  for  the  sake  of  greater  efficacy  mth 
purgation.  The  natural  Hungarian  bitter  waters, 
Carlsbad  water  and  the  less  concentrated  solu- 
tions of  sodium  or  magnesium  sulphate  are  best 
suited  for  the  purpose  provided  there  be  no  kid- 
ney disease. 

Of  the  natural  mineral  waters  not  less  than  two 
tumblerfuls,  heated  to  about  130  deg.  F.,  should 
be  taken  at  one  time,  preferably  in  the  morning. 
If  the  bowels  have  moved  less  than  twice  during 
the  day,  the  dose  should  be  repeated  in  the  late 
afternoon.  If  a  solution  of  sodium  or  magnesium 
sulphate  should  be  prepared  extemporaneously 
not  more  than  one  and  one-half  teaspoonful 
should  be  added  to  each  glass  of  warm  water. 
Two  glasses  of  the  solutions  are  a  dose.  The 
purge  is  to  be  taken  in  the  morning  and,  if  neces- 
sary, also  in  the  early  evening.  In  instances  wth 
impaired  kidney  efficiency  castor  oil  should  be 
substituted  for  the  solutions  of  Epsom  and 
Glauber's  salts.    It  should  be  administered  once 


20  Fasting  and  Undernutrition  in 

a  day  in  doses  from  30  to  60  c.c.  (mils)=l  to  2 
ounces.  Care  must  be  taken  that  it  be  not  ad- 
mixed with  any  sweetening  material. 

In  the  average  case  these  purgatives  must  be 
exhibited  every  day  as  long  as  the  fast  lasts. 
They  should  not  be  replaced  by  any  other  laxa- 
tives, especially  not  by  drugs  containing  sugar, 
such  as  elixirs  of  cascara  sagrada,  magnesium 
citrate,  compound  powder  of  licorice,  etc. 

B.  Drinking, — The  continuance  of  the  normal 
physico-chemical  processes  in  the  organism  de- 
mands that  a  certain  amount  of  liquids  be  im- 
bibed. At  the  same  time  fluids  are  the  carriers 
of  a  great  number  of  excretory  substances. 
Water  may  practically  be  partaken  of  at  pleasure 
by  the  fasting  diabetic  provided  there  is  no  con- 
traindication offered  by  advanced  cardio-vas- 
cular  disease  and  a  general  hydremic  condition. 
The  patient  may  drink  from  20  to  40  c.c.  of  water 
for  each  kilogram  (from  a  little  more  than  % 
ounce  to  somewhat  more  than  1  ounce  for  each 
pound)  of  body  weight  in  the  twenty-four  hours. 
A  man  weighing  60  kilograms  (132  pounds)  may 
therefore  take  daily  from  about  1200  to  2400  c.c. 
(35  to  50  ounces)  of  water.  Only  still  water 
should  be  permitted,  as  carbonated  waters  are 
apt  to  produce  gastro-intestinal  and  vesical  dis- 
comfort. 

Some  of  the  necessary  liquid  may  be  given  in 
the  form  of  a  weak  infusion  of  tea.  Of  course, 
this  must  be  taken  without  milk  or  sugar,  but 


The  Treatment  of  Diabetes  21 

some  lemon  juice  is  permissible.  Three,  four  or 
even  five  cups  of  weak  tea  may  be  drunk  during 
the  twenty-four  hours,  but  the  liquid  thus  im- 
bibed should  be  deducted  from  the  total  amount 
that  is  allowed.  The  tea  (as  well  as  other  fluids) 
ma}^  be  taken  as  warm  as  desired  unless  there  be 
a  gastric  or  duodenal  disease,  ulcer  for  instance. 
Then,  of  necessity,  the  liquids  must  be  taken  luke- 
warm or  cold.  Occasionally  tea  is  not  well-borne ; 
it  may  occasion  headache  or  a  slight  gastric  dis- 
turbance, an  undue  diuresis,  or  it  may  agitate  the 
patient,  preventing  sleep.  In  such  cases  I  am  in 
the  habit  of  ordering  a  very  weak  infusion  of 
chamomile  which  is  a  wholesome  and  satisfactory 
drink.  In  rare  cases  I  permit  coffee.  However, 
it  usually  overstimulates  the  patient  and  the  re- 
action never  fails  to  make  itself  kno^vn.  This 
reaction  manifests  itself  by  a  pathological  de- 
pression. Not  more  than  tw^o  cups  of  rather  weak 
coffee  should  be  allowed  for  each  day  of  the  fast. 
If  the  fast  is  to  be  continued  for  longer  than 
two  days  some  hot  beef  broth,  a  cupful  at  midday 
and  the  same  amount  five  hours  later,  ^vi^  act  as  a 
mild  stimulant.  The  quantity  of  the  broth  should 
also  be  deducted  from  the  total  amount  of  per- 
mitted liquid. 

Sparers  of  body  tissue 

There  are  certain  substances  the  ingestion  of 
which  may  prevent  too  rapid  and  too  pronounced 
a  decline  of  body  weight  when  the  organism  is  in 


22  Fasting  and  Undernutrition  in 

a  state  of  therapeutic  fasting.    The  best  known 
substances  of  this  class  are  alcohol  and  gelatine. 

A.  Alcohol. — Alcohol  is  by  no  means  as  valu- 
able a  saver  of  body  structures  as  gelatine. 
Positive  proof  that  it  saves  the  tissues  in  healthy 
man  is  absolutely  wanting.  However,  alcohol  is 
a  time-honored  adjuvant  in  the  treatment  of  a 
number  of  wasting  diseases,  and  its  stimulating 
action  is  certainly  of  benefit  to  many  patients. 
Small  doses  of  alcohol,  that  is  about  0.5  c.c.  per 
day  for  each  kilogram  of  body  weight  (about  one 
drachm  per  pound)  may  be  permitted.  A  person 
weighing  sixty  kilograms  (132  pounds)  could 
therefore  consume  in  the  neighborhood  of  30  c.c. 
(one  ounce)  of  alcohol  per  day.  As  the  distilled 
liquors  contain  on  the  average  about  fifty  per 
cent,  of  alcohol,  a  patient  of  above  weight  may 
take  60  c.c.  (two  ounces)  of  whiskey  or  brandy  in 
the  twenty-four  hours.  In  exceptional  cases 
twice  the  amount  even  may  be  permitted.  These 
alcoholic  beverages  should  be  well-diluted  with 
plain  water,  and  given  in  small  doses  every  two, 
three  or  four  hours. 

B.  Gelatine. — Gelatine  does  not  appear  to  be 
a  builder  of  body-albumin,  but  it  spares  circula- 
tory proteid.  Hence,  it  prevents  or  limits  the  loss 
of  body-albumin.  The  albumin-saving  property 
of  gelatine  is  at  least  twice  as  large  as  that  of  the 
fats  and  carbohydrates,  as  100  grams  of  it  can 
replace  36  grams  albumin,  that  is  about  175  grams 
of  meat.    Of  course,  the  gelatinous  substances  can- 


The  Treatment  of  Diabetes  23 

not  entirely  prevent  loss  of  tissue  albumin,  and, 
for  this  reason,  a  certain  amount  of  albumins 
proper  must  ordinarily  form  a  constituent  of  the 
nourishment.  In  the  gravest  forms  of  diabetes 
when  glucose  and  ketones  are  being  excreted  in 
considerable  quantities,  the  ingested  gelatine  still 
produces  bodily  energy,  and  averts  rapid  body 
waste  without  increasing  the  sugar  output  in  any 
marked  degree. 

Gelatine  may  also  be  a  sparer  of  body-fat. 
However,  its  influence  in  this  respect  is  more 
limited  than  in  regard  to  the  body-protein.  Still, 
100  grams  gelatin  prevent  disintegration  of  25 
grams  body-fat,  a  fact  which  may  be  made  use  of 
in  the  suppression  of  the  ketone  substances  (ace- 
tone bodies).  In  the  latter  respect  it  is,  indeed, 
a  much  more  valuable  substance  than  alcohol. 

The  tissue-sparing  properties  of  gelatine  are 
only  limited  by  the  comparatively  small  amount 
of  the  substance  which  the  organism  will  tolerate 
without  aversion. 

It  is  always  best  to  have  on  hand  two  or  more 
differently  flavored  gelatines  when  treating  a 
diabetic.  Gelatines  to  which  is  added  some  lemon 
juice  or  some  beef  extract,  beef  juice  and  their 
like  are  especially  cherished  by  the  fasting  pa- 
tient. Such  preparations  may  be  given  alter- 
nately, from  a  teaspoonful  to  a  tablespoonful  at 
a  time.  The  diurnal  intake  should  not  exceed  10 
or  15  grams  (one-third  to  one-half  ounce)  of  gela- 
tine (in  the  raw). 


24  Fasting  and  Undernutrition  in 

Drugs 

Medicines  have  little  or  no  influence  upon  the 
excretion  of  sugar  or  the  ketones  and  are  cer- 
tainly out  of  place  during  the  therapeutic  fast  of 
the  diabetic.  The  much  vaunted,  but  in  the  sup- 
pression of  acidosis  entirely  useless  sodium  bi- 
carbonate, is  included  in  this  pronunciamento. 

Even  if  there  were  any  proof  of  the  antigly- 
cemic  or  antiketonotic  properties  of  certain 
drugs,  their  employ  would  still  be  contraindicated 
in  the  fasting  diabetic  for  the  reason  that  the 
therapeutic  influence  of  the  fast  alone  be  recog- 
nized. This  is  especially  true  in  the  inaugural 
fast. 

Again,  the  fact  must  not  be  lost  sight  of  that 
in  the  fasting  person  most  medicines  exert  their 
physiological  effects  much  more  readily  than  in 
the  individual  that  is  properly  nourished.  If, 
therefore,  the  attending  physician,  for  one  or  the 
other  reason,  does  not  think  he  is  able  to  get 
along  without  a  certain  drug,  he  should,  if  it  be 
a  potent  one,  prescribe  it  in  smaller  than  the  ac- 
customed doses.  Under  all  circumstances,  how- 
ever, he  should  rid  himself  of  the  superstition 
that  any  medicine  which  he  may  order  is  able  to 
control  or  modify  the  sugar  or  acetone  output  of 
his  patient. 

The  average  diabetic  on  a  fast  sleeps  on  and  off 
from  twelve  to  eighteen  hours  per  day.  So  long 
as  his  mental  condition  does  not  prevent  it  he 
falls  asleep  for  similar  reasons  as  the  hibernating 


The  Treatment  of  Diabetes  25 

animal  does.  Should  a  hypnotic  be  necessary, 
morphine  in  doses  from  0.0075  to  0.005  gram  (V12 
to  Vs  gr.)  is  not  alone  the  safest  and  promptest, 
bnt  withal  the  most  valuable  of  this  class  of  reme- 
dies, as  it  retards  the  processes  of  general  meta- 
bolism, thereby  acting  as  a  tissue  sparer. 

Medication  for  local  pathological  states,  as 
gangrene  and  infection,  is,  of  course,  necessary, 
A  remedy  thus  employed  differs  entirely  from  a 
drug  that  is  supposed  to  ameliorate  the  diabetic 
condition  as  such. 


26  Fasting  and  Undernutrition  in 


III 

Breaking  of  the  Fast  and  Undernutritio2S[ 
IN  Diabetes 

"While  the  technic  of  therapeutic  fasting  in  dia- 
betes is  a  rather  simple  matter,  this  is  by  no 
means  the  ease  with  the  breaking  of  the  fast,  for 
this  entails  a  variety  of  precautions  which  I  may 
be  allowed  to  embrace  in  the  principle  ^*  Individ- 
ualization" of  the  patient. 

Individualization  of  the  patient 

There  are  few  measures  demanding  a  stricter 
individualization  of  the  patient  than  the  re-start- 
ing of  eating  without  occasioning  sugar  and  ace- 
tone after  a  therapeutic  fast  of  the  diabetic.  It 
is  not  sufficient  to  render  the  patient  sugar-free 
or,  in  favorable  cases,  free  from  acetone  sub- 
stances. This  freedom  from  sugar,  and  of  ke- 
tones, should  be  maintained  for  as  long  a  period 
as  possible,  provided  the  patient  becomes  not  un- 
duly emaciated  and  feeble  and  a  burden  to  him- 
self and  his  family.  The  moment  the  patient 
rapidly  fails — sugar  or  no  sugar — ^ketones  or  no 
ketones — ,  he  has  to  be  supported  by  a  diet  that 
does  not  keep  him  in  a  state  of  undernutrition. 
It  is  surprising  to  note  how  some  diabetics  thrive 


The  Treatment  of  Diabetes  27 

on  a  diet  that  is  none  too  strict  soon  after  a 
therapeutic  fast.  Of  course,  the  sugar  may  and 
most  ahvays  does  return,  but  the  patient  may  in- 
crease in  body  weight,  strength  and  endurance. 

The  great  majority  of  the  diabetic  patients, 
however,  are  not  benefited  at  all  by  the  fast 
unless  this  be  immediately  followed  by  a  more 
or  less  prolonged  state  of  undernutrition;  and 
furthermore,  there  is  a  small  group  of  diabetics 
which  is  actually  worse  off  after  than  before  the 
fast.  This  is  the  case  when  the  sugar  and  acetone 
excretions  become  quickly  re-established  on  ac- 
count of  a  wrong  diet. 

Fasting  therapy  is  indicated  in  about  twenty 
per  cent,  of  all  the  cases  of  diabetes.  These  cases 
recruit  themselves  from  among  the  severer  types, 
as  a  rule.  In  these  cases  the  course  of  the  dia- 
betic affection  has  either  been  a  rapid  one  right 
from  the  start  or  the  patient  has  had  the  disease 
for  a  long  period.  In  either  eventuality  he  has 
lost  a  good  deal  in  weight,  and  his  bodily  force, 
efficiency  and  resistance  have  markedly  dimin- 
ished. In  patients  of  this  class  the  ordinary 
methods  of  antidiabetic  dieting  usually  no  longer 
avail  much,  and  the  fasting  treatment  must  and 
should  be  given  a  fair  trial.  It  stands  to  reason, 
however,  that  the  management  of  these  cases 
must  be  strictly  individualized.  Neither  should 
the  fast  cause  a  too  rapid  or  too  great  a  decline 
of  body  weight  nor  should  it  cause  diminution  of 
strength  beyond  reasonable  limits. 


28  Fastiintg  and  Undernutrition  in 

Some  medical  enthusiasts  have  declared  that 
the  loss  of  weight  per  se  exerts  a  salutary  in- 
fluence upon  the  diabetic  constitution  and  in- 
creases tolerance  by  allowing  the  diminished 
function  of  the  pancreas  to  recuperate.  Such  an 
assumption  can  only  have  been  dictated  by  purely 
academic  experiments  and  clinical  inexperience. 
In  the  grave  forms  of  diabetes  in  which  a  system 
of  fasting  periods  is  to  be  instituted,  the  motto, 
**To  have  and  to  hold"  must  be  paramount,  and 
be  adhered  to  as  closely  as  possible. 

On  the  other  hand  in  the  general  run  of  cases 
of  diabetes,  furnishing  approximately  eighty  per 
cent,  of  the  affection,  fasting  treatment,  though 
not  invariably  contraindicated,  seems  out  of  place 
as  a  measure  of  routine.  To  this  great  category 
belongs  the  so-called  diabetes  of  the  obese,  usu- 
ally one  of  the  mildest  types  of  diabetes.  Dieting 
or  no  dieting,  obese  diabetics  lose  from  ten  to 
thirty  pounds  on  the  average  during  the  first  year 
of  the  affection.  If  they  are  subjected  to  an  anti- 
diabetic regimen  (which  in  sum  and  substance  is 
identical  mth  an  antiobesity  diet)  they  decline  in 
body  weight  on  account  of  the  ingesta,  changed 
quantitatively  and  qualitatively.  If  on  the  con- 
trary they  continue  to  subsist  on  their  habitual 
food,  they  lose  just  the  same  because  the  diabetic 
deterioration  is  not  being  curbed  and  counter- 
worked. Diabetics  of  this  class  unquestionably 
fare  better  if  they  lose  some  weight;  this,  how- 
ever, will  ensue  at  all  events. 


The  Treatment  of  Diabetes  29 

As  already  stated,  four-fifths  of  all  diabetics 
need  not  ordinarily  submit  to  any  fasting  periods. 
To  be  sure,  fasting  may  not  necessarily  do  any 
harm  in  these  cases,  but  a  strenuous  treatment 
of  this  sort  is  comparable  to  shooting  at  sparrows 
with  cannon  balls. 

The  diet  after  the  inaugural  fast — undernutrition 

First  and  second  days. — When  the  urine  has 
been  sugar-free  for  about  two  days  the  tea,  beef 
broth  and  alcohol,  which  were  allowed  during  the 
fasting  period,  should  be  continued,  the  gelatine 
preparations  may  be  withdra\\Ti,  and  from  three 
to  four  yolks  of  eggs  are  to  be  added  during  the 
subsequent  twenty-four  hours.  The  yolks  are 
best  given  by  incorporating  them  with  the  per- 
mitted liquids.  One-half  of  one  yolk  may  be 
mixed  with  the  tea  at  breakfast  time,  another 
half  with  the  whiskey  around  ten  or  eleven  o  'clock 
in  the  morning,  a  whole  yolk  with  the  broth  at 
the  luncheon  hour;  half  a  yolk  with  tea  at  about 
four  P.M.,  and  a  half  or  whole  yolk  with  whiskey 
in  the  evening.  (Concerning  the  rationale  of  the 
yolk  ingestion  in  the  graver  forms  of  diabetes  see 
page  111.) 

If  a  mixture  of  the  urine  voided  between  six 
P.M.  of  that  day  and  seven  o'clock  the  following 
morning  is  still  free  from  sugar,  the  amount  of 
broth  and  yolks  may  be  doubled  while  that  of 
tea  and  alcohol  should  remain  unchanged.  If  the 
urine  derived  from  the  period  between  six  P.M. 


30  Fasting  and  Undernutrition  in 

and  seven  A.M.  does  not  show  clinically  demon- 
strable amounts  of  sugar,  the  following  dietary 
for  the  third  and  fourth  days  after  breaking  the 
fast  may  be  ordered. 

Third  and  fourth  days. — 

Breakfast:  Cup  of  tea  or  coifee,  without  milk  or 
sugar. 
Two  soft-boiled  eggs  with  two  extra  yolks. 

10.30  A.M.:  Egg-nog  (20  c.c.  (V3  ounce)  whiskey, 
75  c.c.  (2%  ounces)  water,  one  egg  yolk). 

Midday:  One  or  two  plates  of  beef  broth  (pre- 
pared with  green  vegetables,  such  as  parsley, 
leak  or  onion,  celery  tops,  strained)  with  one 
yolk  per  plate  stirred  in. 
Spinach,  dessert-plateful  (75  grams=2% 
ounces)  with  one  whole  egg, 

4  P.M.:  Whiskey  (20  c.c.^Vs  ounce)   with  one 
yolk. 

Supper:  One  plate  of  beef  broth  (as  above),  with 
one  yolk  stirred  in. 

String  beans,  dessert-plateful    (75  grams = 
2%  ounces). 

Lettuce  with  French  dressing  and  one  or  two 
yolks. 

It  is  not  necessary  that  the  urine  of  the  third 
day  after  breaking  the  fast  be  examined.  The 
urine  of  the  fourth  day,  which  is  to  be  accumu- 
lated for  the  same  period  six  P.M.  to  seven  A.M. 


The  Treatment  of  Diabetes  31 

(the  fifth  day)  will  tell  the  story  much  better.  If 
it  contains  no  sugar,  the  following  diet  for  the 
fifth  day  may  be  proceeded  with. 

Fifth  day. — 

Breakfast:  Cup  of  tea  or  coffee,  without  milk  or 
sugar. 

Two  soft  boiled  eggs  ^\\t\\  two  extra  yolks. 
Two  slices  of  bacon. 

10.30  A.M.:  Egg-nog  as  on  previous  day. 

Midday:  One  or  two  plates  of  beef  broth  (pre- 
pared as  on  pre^dous  days),  mth  one  yolk 
stirred  in  for  each  plate. 
Spinach,     soup     plateful     (125     grams=4J 
ounces)  with  two  whole  eggs. 
Four  oil  sardines. 
String  bean  salad  (French  dressing). 

4  P.M.:  "Whiskey  (20  c.c.^Vs  ounce)   wdth  one 
yolk. 

Supper:  One  plate  of  chicken  broth,  with  three 
tablespoonfuls  of  cut  giblets. 
Brussels  sprouts  or  kohlrabi,  seasoned,  but 
without  butter  or  flour,  dessert-plateful  (75 
grams=2i/2  ounces). 

Salad  of  canned  asparagus  (eight  to  twelve 
whole  asparagus). 
American  cheese  (30  grams=one  ounce). 

If  after  this  diet  there  occurs  no  urinary  sugar, 
a  larger  amount  of  protein  in  the  form  of  meat 
may  be  added  to  the  food  of  the  sixth  day. 


32  Fasting  and  Undeknutrition  in 

Sixth  day. — 

Breakfast:  Cup  of  tea  or  coffee,  without  milk  or 
sugar. 

Ham  (or  bacon)  and  eggs  (two  eggs,  30  grams 
=one  ounce  ham  or  bacon). 

10.30  A.M.:  Egg-nog  (as  on  previous  days). 

Midday:  One  or  two  plates  of  green  vegetable 
soup  (parsley,  celery,  onion,  cabbage,  cauli- 
flower). 

Breast  of  chicken  (40  grams^lVs  ounce). 
String  beans,  dessert-plateful. 
Lettuce  or  watercress,  French  dressing. 

4  P.M.:  Whiskey  (20  c.c— Vg  ounce),  or  tea,  with 
one  yolk. 

Supper:    One  or  two  plates  of  green  vegetable 
soup  (as  above). 
Cabbage,  dessert-plateful. 
Dandelions  or  field  salad,  dessert-plateful. 
American  cheese  (30  grams=one  ounce). 

If  the  urine  continues  to  be  free  from  sugar, 
the  following  sample  of  a  diet  may  serve  for  the 
seventh  day  of  undernutrition  following  the  fast. 

Seventh  day. — 

Breakfast:  Cup  of  tea  or  coffee,  without  milk  or 
sugar. 

Ham    (or  bacon)    and  eggs    (two   eggs,  40 
grams =1V3  ounce  ham  or  bacon). 

10.30  A.M.:  Egg-nog  (as  on  previous  days). 


The  Treatment  of  Diabetes  3 


o 


Midday:  One  plate  of  chicken  broth  with  half 
tablespoonful  of  rice  (cooked) ;  some  chicken 
giblets. 

One  lamb  chop,  or  a  slice  of  any  meat  (50 
grams =1V3  ounce). 

Spinach,   string  beans,   or  Brussels   sprouts 
(one  even  soup-plateful). 
Lettuce,  French  dressing,  as  much  as  de- 
sired. 

4  P.M.:  Whiskey  (20  c.c),  or  tea,  ^^dth  one  yolk. 

Supper:  One  plate  of  chicken  broth,  \vithout  rice, 
but  with  some  chicken  giblets  (three  table- 
spoonfuls). 

Any  green  vegetable   (one  even  soup-plate- 
ful).    Eomaine  or  endive,  French  dressing, 
as  much  as  desired. 
Brazil  nuts  (30  grams==one  ounce). 

After  a  week,  then,  the  patient  obtains  a  daily 
ration  yielding  betw^een  1000  and  1100  of  avail- 
able calories.  This  is  approximately  one-third 
less  than  he  should  receive  at  the  end  of  the  fol- 
lowing week,  and  about  half  of  the  caloric  food 
value  he  should  be  allowed  at  the  end  of  the  third 
week  after  the  fast,  provided  his  urine  be  still 
free  from  sugar. 

During  the  period  of  undernutrition,  that  is, 
so  long  as  the  diabetic  patient  ingests  food  less 
than  will  yield  about  thirty-five  calories  per  kilo- 
gram of  body  w^eight,  he  cannot,  of  course,  pursue 
his  usual  occupation.     It  is  not  quite  necessary 


34  Fasting  and  Undernutrition  in 

that  he  be  resting  all  the  time,  but  he  shonld  take 
only  very  moderate  exercise  and  be  in  bed  for 
not  less  than  from  fourteen  to  eighteen  out  of 
the  twenty-four  hours. 

Second  week  of  undernutrition 

The  bulk  of  the  increase  in  calories  during  the 
second  week  after  the  inaugural  fast  should  de- 
rive from  the  fats  of  high  melting  point.  For 
reasons  set  forth  elsewhere  (pages  111,  133)  the 
yolk  of  the  hen's  Qgg  contains  the  fatty  substances 
best  suited  for  this  purpose.  For  the  very  same 
reasons  cream  and  butter  should  be  withheld 
strictly.  The  daily  ingestion  of  from  ten  to  fif- 
teen yolks,  properly  incorporated  with  the  other 
food,  almost  every  diabetic  will  submit  to  for  a 
few  weeks.  This  number  of  yolks  yields  approxi- 
mately from  500  to  750  calories.  The  addition 
of  but  even  ten  yolks  to  the  diet  of  the  seventh 
day  (see  before)  would  almost  make  up  for  the 
daily  caloric  deficit  during  the  second  week. 
However,  an  increased  amount  of  green  vege- 
tables and  some  more  protein  (egg-white,  meat, 
fish)  may  be  allowed  to  help  in  overcoming  the 
caloric  inadequacy. 

In  this  connection  I  wish  to  state  that  the  deter- 
mination of  the  fat-tolerance  is  hardly  necessary 
as  far  as  the  production  of  urinary  sugar  is  con- 
cerned. The  fat-tolerance  should  be  ascertained 
because  the  low  fatty  acids  may  be  possible 
progenitors   of  the   ketone   substances    (acetone 


The  Treatment  of  Diabetes  35 

bodies).  In  many  hundreds  of  cases  of  diabetes 
in  which  I  have  employed  the  **yolk  cure,"  I  have 
seen  a  heightened  intensity  degree  of  the  glyco- 
suric  SATiiptom  in  less  than  half  a  dozen  instances, 
while  an  increased  ketonuria  ensued  in  not  more 
than  three  or  four  per  cent,  of  the  patients.  An 
ordinary  yolk  contains  over  five  grams  of  fat. 
Ten  yolks  embody  therefore  somewhat  more  than 
fifty  grams  of  fatty  material.  This  is  less  than 
one  gram  per  kilogram  of  body  weight  of  the 
average  patient.  x\s  a  matter  of  fact,  the  gen- 
eral case  of  diabetes  undergoing  the  undernutri- 
tion treatment  may  have  in  the  second  week  after 
the  fast  as  much  as  two  or  three  grams  of  fat  of 
high  melting  point  per  kilogram  of  body  weight. 

Method  of  adding  food 

The  food-increase  should  occur  slowly  and  in 
the  manner  that  not  more  than  one  and  a  half 
calories  per  day  and  kilogram  of  body  weight  be 
added.  A  man  weighing  60  kilograms  (132 
pounds)  should  therefore  receive  a  daily  addition 
of  ninety  calories  from  day  to  day.  This  means 
more  than  six  hundred  additional  calories  on  the 
last  day  of  the  week.  Together  wdth  the  food  of 
the  seventh  day  of  undernutrition  (after  the  fast) 
when  the  number  of  calories  available  from  the 
food  amounted  to  from  one  thousand  to  eleven 
hundred,  this  patient  hence  partakes  at  the  end  of 
the  second  week  (after  the  fast)  of  an  amount 
of  nutriment  almost  maintaining  him  in  a  state 


36  Fasting  and  Undernutrition  in 

of  metabolic  equilibrium.  His  decline  in  body 
weight  should  not  surpass  one  to  two  kilograms 
(two  to  four  pounds)  during  the  second  week  of 
undernutrition. 

Here  follows  a  sample  dietary  for  the  first 
three  days  of  the  second  week  (eighth,  ninth  and 
tenth  days)  after  the  fasting  period.  The  figures 
in  brackets  are  for  the  ninth  and  tenth  days,  re- 
spectively. 

First  three  days  of  second  week 

Breakfast:  Cup  of  tea  or  coffee,  without  milk, 
cream  or  sugar. 

Bacon  and  eggs  (3  eggs),  1st  day  50  grams, 
2nd  day  60,  3rd  day  70  grams  bacon. 

10.30  A.M.:  Egg-nog  (whiskey  20  c.c,  two  yolks). 

Midday:  One  plate  (2nd  and  3rd  days  2  plates) 
vegetable  soup  (parsley,  celery,  onion,  cab- 
bage, cauliflower,  tomatoes,  unstrained  if 
desired). 

Fish,  mackerel  or  shad,  boiled  or  broiled,  ^gg 
sauce,  30  grams  (40,  50  grams  2nd  and  3rd 
days  resp.). 

Beef  in  any  form,  one  small  slice,  medium 
fat,  70  grams. 

Cauliflower,  60  grams  (70,  80  grams  2nd  and 
3rd  days  resp.). 

String  beans,  60  grams  (70,  80  grams  2nd  and 
3rd  days  resp.). 

Cold  slaw,  French  dressing,  as  much  as  de- 
sired. 


The  Treatment  of  Diabetes  37 

4  P.M.:  Whiskey,  20  c.c,  or  tea,  with  one  yolk 

(2  yolks  2n(i  and  3rd  days  resp.). 
Supper:  Four  oysters  (5,  6  oysters  2nd  and  3rd 

days  resp.). 

One  plate  of  beef  or  mutton  broth. 

Omelette,  two  eggs. 

Spinach,  100  grams. 

Any  green  salad,  French  dressing,  as  much 

as  desired. 
The  available  calories  of  this  diet  vary  from 
about  1150  on  the  eighth  to  about  1325  on  the 
tenth  day.  By  the  end  of  the  second  week  the 
patient  should  take  approximately  the  following 
dietary  in  case  the  urine  has  remained  free  from 
sugar. 

End  of  second  week  after  fast 

Breakfast:  Cup  of  tea  or  coffee,  with  one  yolk, 
but  without  milk,  cream  or  sugar. 
Bacon  and  eggs  (3  eggs,  80  grams  bacon). 

10.30  A.M.:  Egg-gelatine  (one  whole  ^gg,  one  ex- 
tra yolk). 

Midday:  One  plate  of  okra  soup  (some  green 
vegetables,  tomatoes,  teaspoonful  of  oat- 
meal). 

Salmon,  smoked,  40  grams. 
Bean  salad,  150  grams. 
Beef  in  any  form,  medium  fat,  100  grams. 
Spinach,  100  grams. 

Egg-salad  (2  eggs),  lettuce,  French  dressing. 
Brazil  nuts  (30  grams  without  shells). 


38  Fasting  and  Undernutrition  in 

4  P.M.:  CofPee-gelatine  (half  teaspoonful  pow- 
dered gelatine,  two  table  spoonfuls  water, 
three  quarter's  cup  boiling  coffee). 

Supper:  Anchovies  or  sardines  in  .oil  (3). 

Chicken  broth  with  half  a  tablespoonful  of 

fine  noodles. 

Asparagus  omelet  (three  eggs,  eight  stalks 

asparagus). 

Cauliflower,  100  grams,  with  yolk  sauce  (two 

yolks). 

Eipe  olives  (40  grams). 
The  foodstuffs  in  the  last  diet  list  yield  no  less 
than  from  1750  to  1800  calories,  an  amount  on 
which  a  patient  weighing  sixty  kilograms  (132 
pounds)  can  very  well  get  along  for  some  time  if 
he  be  at  rest  the  greater  part  of  the  twenty-four 
hours. 

Third  week  after  the  fast 

By  the  end  of  the  third  week  after  the  fast,  the 
patient — in  successful  cases— will  be  able  to  in- 
gest food  yielding  about  40  calories  per  day  and 
kilogram  of  body  weight  without  giving  rise  to 
either  glycosuria  or  ketonuria.  At  the  same  time 
he  should  not  have  lost  more  than  from  six  to 
eight  kilograms  (13  to  17%  pounds)  in  weight, 
and  be  rather  more  vigorous  (resistant)  than  be- 
fore he  started  to  fast.  If  this  be  not  the  case 
the  method  of  treatment  here  outlined  is  a  failure 
in  this  particular  instance.  Eecalling  to  mind 
that  only  in  the  severest  forms  of  diabetes  the 


The  Treatment  of  Diabetes  39 

fasting-underniitrition  method  should  find  em- 
ployment, it  will  at  once  be  seen  that  the  differ- 
ence between  1800  calories  at  the  end  of  the 
second,  and  2400  calories  at  the  end  of  the  third 
week,  cannot  be  made  np  by  carbohydrates  alone. 
Moreover,  experience  has  shown  that  the  inges- 
tion of  vegetables  containing  five  or  ten  per  cent, 
carbohydrate  in  amounts  larger  than  400  grams, 
is  practically  useless  for  the  human  economy  in- 
asmuch as  the  intestinal  juices  in  a  severe  case 
of  diabetes  are  insufficient  to  elaborate  the 
starchy  material  from  the  mass  of  cellulose  tex- 
tures. The  additional  carbohydrate  must,  there- 
fore, be  derived  from  vegetables  containing  a 
higher  percentage  of  starchy  material.  At  the 
same  time  it  should  be  easier  of  elaboration. 

The  tolerance  for  carbohydrate  as  such  in  the 
severer  forms  of  diabetes  is  always  below  fifty 
grams  per  day ;  often  it  is  nil.  These  fifty  grams 
carbohydrate  yield,  at  the  best,  200  calories. 
Vegetables  with  a  low  carbohydrate  content  (five 
per  cent,  or  less),  for  reasons  just  mentioned, 
hardly  furnish  any  starchy  material  to  the  dia- 
betic organism.  They  fill  the  gastro-intestinal 
tract,  giving  thereby  a  certain  feeling  of  satia- 
tion; they  also  supply  a  certain  amount  of  vari- 
ous salts,  but  they  do  not  contribute  to  any  extent 
to  the  combustion  processes  within  the  body.  In 
planning  the  food  intake  up  to  the  end  of  the 
third  week  after  fasting,  it  wdll  be  found  that, 
as  far  as  their  nutritive-calorific  value  is  con- 


40  Fasting  and  Undernutrition  in 

cerned,  the  green  vegetables  by  themselves  have 
not  been  taken  by  me  into  any  account  whatever. 
They  are  solely  added  to  the  dietaries  in  order  to 
meet  physical  and  mental  satisfaction. 

Favorable  cases,  those  which  have  hitherto  re- 
mained sugar  and  ketone-free,  should  receive 
about  ten  grams  more  fatty  material  (no  cream 
or  cheese)  and  the  same  amount  of  protein  every 
other  day  during  the  ensuing  week.  Further- 
more, these  patients  should  be  tested  for  their 
carbohydrate  tolerance.  For  this  purpose  I  pre- 
fer the  small,  hard  potato  (new,  if  possible) 
which  contains  approximately  twenty  per  cent, 
starch.  I  order  the  potatoes  in  any  of  the  fol- 
lowing forms:  Boiled  in  their  jackets;  French 
fried,  or  Saratoga  chips. 

Determination  of  carbohydrate  tolerance^ 

The  patient  receives  the  diet  of  the  end  of  the 
second  week  after  the  fast  (or  its  equivalent) 
and  the  fat  and  protein  addition  just  pointed 
out.  To  this  is  added  five  grains  potato  in  the 
form  of  Saratoga  chips  at  the  midday  meal.  If 
the  urine  for  the  ten  hours  following  the  potato 
intake  be  sugar-free,  five  grams  of  the  Saratoga 
chips  may  be  again  added  to  the  midday  meal  of 
the  following  day ;  in  addition  five  grams  of  the 
same  may  also  be  incorporated  with  the  supper 
of  this  day. 

In  case  the  urine  voided  between  1  P.M.  and 
7  A.M.  the  next  day  is  sugar-free,  seven  one-half 


The  Treatment  of  Diabetes  41 

grams  of  the  chips  should  be  added  to  the  mid- 
day repast  and  the  same  amount  to  the  supper. 
If  the  afternoon-evening-night  urine  shows  no 
sugar,  the  patient  may  have  twenty  grams  chips, 
ten*  grams  respectively  for  the  midday  and  even- 
ing meals.  If  sugar  cannot  be  demonstrated  in 
the  urine  twenty-five  grams  chips,  half  at  noon 
and  half  in  the  evening,  should  be  allowed  on 
the  following  day. 

In  case  the  urine  continues  to  be  sugar-free  the 
twenty-five  grams  of  potato  chips  should  be  con- 
tinued for  a  week  or  ten  days  as  part  of  the 
daily  ration  of  the  patient.  After  this  period  the 
tolerance  determination  for  carbohydrate  may  be 
continued,  but  in  the  manner  that  only  very  small 
amounts  of  the  carbohydrate,  say  two  or  three 
grams,  be  added  every  day  or,  what  is  still  better, 
every  other  day.  However,  it  will  be  found  that 
but  few  of  the  severe  cases  of  diabetes  will  toler- 
ate more  than  thirty  or  thirty-five  grams  avail- 
able carbohydrate  from  day  to  day. 

In  exceptional  cases  the  carbohydrate  toler- 
ance increases  for  a  certain  period  or  from  time 
to  time.  With  the  essentially  identical  intake  of 
food  the  carbohydrate  tolerance  becomes  sud- 
denly greater  so  that  no  glycosuria  supervenes 
after  thirty  or  even  forty  grams  of  carbohydrate, 
whereas  on  the  previous  day  fifteen  and  more 
grams  of  glucose  were  excreted  with  the  urine. 
This  phenomenon  generally  disappears  as  rap- 
idly as  it  has  ensued  and,  in  my  opinion,  has 


42  Fasting  and  Undernutrition  in 

nothing  to  do  with  sparing  of  the  function  that 
presides  over  the  carbohydrate  metabolism. 

Subsequent  diet 

The  subsequent  diet-question  in  severe  cases  of 
diabetes  resolves  itself  in  particular  in  the  de- 
crease or  occasional  re-increase  of  the  carbohy- 
drate intake  and  the  periodical  interspersing  of 
fast  days.  In  this  respect  the  dietary  manage- 
ment of  severe  cases  of  diabetes  following  an  in- 
augural fast  and  the  graded  system  of  under- 
nutrition does  not  differ  essentially  from  that 
championed  by  the  writers  of  half  a  generation 
ago.  This  management  of  the  patient  is  nothing 
else  but  a  continuous  piloting  between  the  devil 
and  the  deep  sea.  On  the  one  side  the  greater 
intensity  degree  of  the  sugar  output,  on  the  other 
side  the  re-appearance  or  augmentation  of  the 
ketonosis. 

However,  I  am  certain  that  a  mild  ketonuria 
is  much  less  of  a  danger  signal  than  we  are  wont 
to  believe.  Many  of  my  patients  exhibited  this 
phenomenon  for  months  and  months,  without 
noticeable  injury  to  their  general  well-being.  If 
I  have  to  choose  between  the  production  or  the 
continuation  of  a  mild  ketonuria  and  the  sup- 
pression of  a  high-degree  glycosuria,  I  never  hesi- 
tate to  counterwork  the  latter.  It  is  true  enough 
that  the  inaugural  fast  will  often  work  wonders, 
but  even  in  the  successful  cases  this  influence  will 
not  endure  for  a  protracted  period.    Other  fast- 


The  Treatment  oi*  Diabetes  43 

ing  periods  should  be  intercalated ;  in  some  cases 
when  called  for,  in  others  as  a  routine  practice. 
Taking  it  all  in  all,  the  food  intake  at  the  end 
of  the  third  week  following  the  completion  of  the 
inaugural  fast  (when  the  provisional  determina- 
tion of  the  carbohydrate  tolerance  has  been  ac- 
complished) is  a  fair  example  of  the  subsequent 
dieting  in  the  severe  forms  of  diabetes. 

Subsequent  fasting  periods 

Cases  under  observation  from  the  beginning  of 
the  inaugural  fast  until  the  end  of  the  third  week 
of  graded  undernutrition,  having  shown  no  uri- 
nary sugar  since  the  second  or  third  day  of  the 
fast,  need  not  be  submitted  to  any  subsequent 
fast  during  this  period.  At  the  end  of  the  fourth 
week,  however,  w^hen  the  patient  is  receiving  in 
the  neighborhood  of  forty  calories  per  day  and 
kilogram  of  body  weight,  a  fasting  period  of 
about  thirty-four  hours  should  be  interpolated. 
Weekly  thereafter,  so  long  as  he  receives  from 
thirty-five  to  forty  calories  per  day  and  kilogram, 
the  patient  should  undergo  a  fast  of  the  same 
length.  The  fast  should  be  taken  under  this  con- 
dition even  in  case  the  urine  of  the  past  week 
should  have  proved  sugar-free. 

I  generally  let  the  patient  start  his  thirty-four 
hours'  fast  in  the  afternoon  of  Saturday  (half- 
holiday)  and  let  him  continue  it  until  Sunday 
evening.  He  omits  the  midday  and  evening  meals 
on  Saturday  and  the  breakfast  and  midday  meals 


44  Fasting  and  Undernutrition  in 

on  Sunday.  At  about  five  or  six  o'clock  on  Sun- 
day evening  I  let  the  patient  have  a  light  meal 
composed  of  oysters  or  broth,  two  or  three  eggs, 
some  green  salad,  spinach  and  asparagus.  On 
Monday  morning,  after  having  had  his  usual 
breakfast,  he  is  ready  to  attend  to  his  business 
affairs  until  the  following  Saturday  afternoon, 
when  the  same  routine  is  going  to  be  repeated. 

In  some  cases  a  two-days'  fast  is  necessary  to 
regulate  the  metabolic  unbalance.  These  two- 
days'  fasts  may  also  be  submitted  to  in  periodic 
intervals,  and  it  may  be  necessary  to  intercalate 
two-days '  fasts  every  week.  However,  more  than 
three  or  four  times  in  succession  fasts  of  that 
duration  should  not  be  ordered  as  the  patients 
will  lose  weight  and  strength  too  rapidly. 

Every  fast  day,  of  course,  lowers  the  patient's 
weight.  With  from  thirty  to  forty  calories  per 
day  and  kilogram  of  body  weight  the  diabetic  in- 
dividual may  just  maintain  his  own.  The  inter- 
calated thirty-four  hours  fasting  will  invariably 
reduce  his  weight  for  not  less  than  one  to  one 
and  a  half  kilograms  (two  to  three  pounds).  As 
a  matter  of  fact  a  loss  of  from  three  to  four  kilo- 
grams (six  and  one-half  to  almost  nine  pounds) 
is  not  rare.  Patients  holding  their  own  will  make 
up  this  loss  almost  entirely  before  the  next 
weekly  fast.  However,  there  must  be  a  limit  in 
the  decline  in  body  weight,  and  hence  also  in  the 
number  of  fast  days. 

Some  recent  writers  have  made  a  virtue  of 


The  Treatment  of  Diabetes  45 

necessity,  maintaining  that  the  loss  of  weight  is 
a  boon  for  the  diabetic  patient.  This,  as  has  al- 
ready been  shown,  is  true  to  a  certain  extent  so 
far  as  the  mild  cases  of  diabetes,  especially  those 
occurring  in  association  with  obesity,  are  con- 
cerned. Severe  cases  of  diabetes,  on  the  other 
hand,  should  undergo  fasting  and  undernutrition 
out  of  dire  necessity  only.  They  must  live,  for 
the  time  being,  in  conformity  with  the  restricted 
intake,  but  they  should  lose  as  little  as  possible 
in  body  weight.  In  severe  diabetes,  decline  of 
body  weight  goes  in  nearly  every  instance  hand 
in  hand  with  decline  in  body  strength  and  sys- 
temic resistance. 

It  will  be  found  that  in  the  course  of  time  com- 
plete fasting  periods  cannot  be  intercalated  any 
longer  in  any  of  the  cases.  They  will  debilitate 
the  patient  more  than  they  vnll  detoxicate  him, 
and  they  cannot  be  continued  sufficiently  long  so 
that  in  advanced  instances  the  urinary  sugar  can 
be  any  longer  materially  reduced.  As  every 
therapeutic  measure  so  fasting  in  diabetes  has  its 
natural  limits. 

However,  while  fasting  as  such  may  no  longer 
be  applicable  (and  for  obvious  reasons  this  will 
occur  sooner  in  private  than  in  institutional  prac- 
tice), undernutrition  may  be  resorted  to  in  those 
stages  of  severe  diabetes  in  which  fasting  is  no 
longer  of  demonstrable  value.  Here  the  food  in- 
take of  the  second  or  the  first  week  after  the 
inaugural  fast  may  be  of  service. 


46  Fasting  and  Undernutrition  ii?" 

Water  during  undernutrition 

Besides  the  liquids  pointed  out  in  the  various 
dietaries  the  patient  during  the  period  of  under- 
nutrition may  take  as  much  water  as  is  consistent 
with  a  good  gastric  digestion  and  general  com- 
fort. As  soon  as  the  sugar  output  has  materially 
diminished,  it  will  be  found  that  the  patient  has 
little  inclination  to  drink  more  than  small  amounts 
of  water.  When  this  is  the  case  the  patient  must 
be  made  to  drink  water,  that  is  to  say  he  should 
imbibe  not  less  than  one  liter  during  the  twenty- 
four  hours.  Aerated  waters  are  apt  to  cause 
gastro-intestinal  and  even  vesical  distress  for 
which  reasons  they  should  not  be  permitted  in 
the  general  run  of  the  eases. 

When  the  patient  is  in  a  state  of  undernutri- 
tion he  should  take  but  small  quantities  of  water 
at  any  one  time.  Each  drink  should  not  exceed 
one  hundred  cubic  centimeters  (three  ounces). 
Before  the  night's  rest  especially,  the  water 
should  be  taken  sparingly.  Chopped  ice  is  a  very 
good  form  in  which  to  carry  water  into  the 
system. 

Evacuation  of  the  bowels 

The  movements  of  the  bowels  during  the 
periods  of  undernutrition  are  nearly  always 
sluggish.  Assistance  has  to  be  rendered  by  some 
artificial  means.  An  enema  is  often  all  that  is 
needed;  one  of  soap-suds  and  oil  is  to  be  pre- 
ferred.   It  must  be  administered  daily,  as  a  rule. 


The  Treatment  of  Diabetes  47 

Epsom  salts  may  render  good  service  in  instances 
where  kidney  disease  can  positively  be  excluded. 
Its  dose  must  presumably  be  increased  every  few 
days.    It  should  be  administered  daily. 

In  the  long  run  phenolphthalein  or  aloin  in 
combination  with  some  carminative  should  be 
prescribed.  These  preparations  are  best  given 
at  bedtime. 

Castor  oil  in  sufficiently  large  doses  should  be 
ordered  to  be  taken  once  or  twice  each  week  if 
the  intestinal  evacuations  are  not  as  copious  as 
they  ought  to  be  after  the  exhibition  of  afore- 
mentioned expedients. 

Rest  during  undernutrition 

It  is  imperative  that  the  diabetic  patient  in  the 
state  of  undernutrition  has  a  good  deal  of  rest. 
Eest  in  bed  is,  of  course,  the  best.  Some  diabetics 
need  considerably  more  rest  than  others.  How- 
ever, twelve  hours  in  bed  during  the  twenty-four 
hours  should  be  the  minimum.  Many  diabetics 
get  along  vdth.  very  little  sleep;  they  hate  the 
bed.  Sedatives  and  h^^notics  should  not  be  ad- 
ministered to  such  patients,  but  they  must  learn 
to  rest  their  bodies  and  brains  without  sleeping. 
Mild  exercise  like  walking  is  permissible  if  the 
patient's  strength  allows  it. 


48  Fasting  and  Undernutrition  in 

IV 

Failures 

Thus  far  detailed  descriptions  were  given  of 
the  technic  of  the  fast  in  severe  forms  of  dia- 
betes, of  the  breaking  of  the  fast,  and  of  the  sub- 
sequent graded  system  of  undernutrition.  Occa- 
sionally only  allusion  has  been  made  that  the 
sailing  is  not  always  an  easy  one,  and  that  there 
are  cases  unsuccessfully  treated  by  this  combina- 
tion method. 

It  has  already  been  stated  that  the  overwhelm- 
ing majority  of  diabetics  need  not  submit  to  a 
dietetic  juggling  that  has  neither  any  raison 
d^etre  in  the  ordinary  diabetic  economy,  nor  will 
or  can  or  is  even  expected  to  do  more  good  than 
is  accomplished  by  the  approved  methods  of  dia- 
betes therapy.  The  advanced  and  severer  forms 
of  diabetes  alone — forming  about  twenty  per 
cent,  of  all  the  cases  of  the  affection — are  those 
that  should  be  submitted  to  the  prolonged  fast- 
ing-undernutrition  method.  Of  these  consider- 
ably more  than  half  are  markedly  benefited  by 
this  plan  of  treatment,  about  one-fifth  of  the  pa- 
tients are  not  influenced  by  it  one  way  or  the 
other,  and  the  general  condition  (and  sometimes 
also  the  glycosuria  and  ketonuria)  becomes  un- 
questionably aggravated  in  about  five  per  cent, 
of  the  instances. 


The  Treatment  of  Diabetes  49 

Peremptory  failures 

For  the  present  it  may  suffice  to  know  that 
many  of  the  ultimate  successful  cases  may  prove 
failures  for  a  time  on  account  of  a  wrong  technic 
or  for  some  other  reason.  However,  there  are 
always  some  patients — a  comparatively  small 
number,  it  is  true — who  are  and  remain  peremp- 
tory failures. 

Now,  what  is  a  peremptory  failure!  Among 
the  peremptory  failures  I  count  those  cases  in 
which  an  existing  glycosuria  on  prolonged  fast- 
ing does  not  decrease  or  disappear  altogether, 
and  in  which  the  ketonuria  does  not  diminish  in 
the  ratio  in  which  body  weight  and  vigor*  decline. 
Cases  in  which  the  glycosuria  disappears  while 
the  ketonuria  persists  I  do  not  classify  as  peremp- 
tory failures,  as  the  majority  of  the  diabetic  cases 
with  ketonosis  treated  by  prolonged  fasting  still 
show  evidence  of  acetonuria.  (As  a  matter  of 
fact,  however,  the  ketone  content  is,  as  a  rule, 
more  or  less  diminished  after  a  fast  of  from  four 
to  six  days.)  Moreover,  there  are  cases  which 
are  free  from  ketonuria  on  a  certain  day  of  the 
fast  and  which  again  exhibit  acetone  during  the 
following  twenty-four  hours.  And  again,  there 
are  cases  in  which  a  prolonged  fast  has  caused 
the  disappearance  of  ketonuria,  while  in  the  same 
patient,  a  fast  of  even  greater  length  a  month 
later  failed  to  accomplish  this  feat. 

It  stands  to  reason  that  cases  can  only  be 
counted   among  the   peremptory   failures   after 


50  Fasting  and  Undernutrition  in 

varions  attempts  at  protracted  therapeutic  fast- 
ing have  been  made.  The  cases  do  not  bear  the 
imprint  of  peremptory  failures  upon  their  fore- 
heads. If  they  would,  some  useless  treatment, 
not  to  say  suffering,  could  be  avoided.  A  num- 
ber of  writers  following  the  lead  of  v.  Noorden 
assert  that  in  the  really  severe  forms  of  diabetes 
the  loss  of  weight  sustained  on  a  fast  day  is  rap- 
idly made  up  or  considerable  increase  even  is  ob- 
tained, on  the  addition  of  one  hundred  grams 
carbohydrate  to  the  food.  Every  clinician  with 
some  experience  in  the  treatment  of  diabetes 
knows  that  this  is  by  no  means  the  case  in  the 
general  run  of  the  severe  cases,  that  it  is  nearly 
always  an  impossible  task  to  make  the  diabetic 
affected  with  a  grave  type  of  the  disease  regain 
what  he  has  lost  through  restricted  diet  in  gen- 
eral and  fasting  in  particular ;  and  that  the  clini- 
cian can  consider  himself  rather  lucky  if  he  is 
able  to  avert  any  further  decline  of  his  patient's 
physical  condition. 

Cases  proving  peremptory  failures  not  only 
belong  to  this  category  on  account  of  the  unim- 
proved urinary  condition,  but  also — and  this  is 
the  crux  of  the  entire  question — on  account  of  the 
aggravation  of  the  peculiar  physical  circum- 
stances of  the  patient.  While  autotoxic  phenom- 
ena play  a  certain  role  in  advanced  or  severe 
forms  of  diabetes,  they,  by  no  means,  dominate 
the  entire  clinical  picture.  The  peculiar  mus- 
cular weakness  of  the  diabetic,  the  grave  lassi- 


The  Treatment  of  Diabetes  51 

tude  culminating  in  listlessness,  the  entire  want 
of  emotion  and  the  absence  of  *Hhe  will  to  live'' 
are  symptoms  of  undernutrition  and  not  of  auto- 
intoxication. In  grave  diabetes  danger  from 
starvation  is  just  as  much  a  possibility  as  is 
danger  from  autointoxication,  and,  under  exist- 
ing circumstances,  one  cannot  readily  differen- 
tiate between  the  beginning  of  the  one  and  the 
termination  of  the  other. 

Cases  of  this  sort  should,  of  course,  not  be 
subjected  to  prolonged  fasting  or  undernutrition. 
The  occasional  omission  of  a  few  meals  in  order 
to  at  least  reduce  the  degree  of  the  glycosuria 
may  be  tried.  The  reduction  of  the  starch  intake 
to  a  minimum  must  never  be  carried  out  for 
longer  than  a  day  or  a  day  and  a  half.  In  some 
of  my  cases  I  have  succeeded  tolerably  well  for 
a  time  by  withdramng  the  more  substantial 
starch  carriers  every  third  day,  that  is  by  placing 
the  patients  on  a  diet  consisting  of  yolks,  bacon, 
whiskey,  spinach  and  lettuce,  and  keeping  them 
in  bed  during  this  time.  In  a  very  few  cases  I 
could  even  intercalate  one  of  these  restricted  diet 
days  every  other  day.  In  other  instances,  how- 
ever, it  is  not  permissible  to  intercalate  one  of 
these  restricted  days  oftener  than  every  fifth, 
sixth  or  seventh  day  without  doing  some  real 
harm  to  the  patient.  At  any  rate,  many  of  these 
cases  which  are  out-and-out  failures  at  fasting 
and  continued  starvation  may  get  along  in  com- 
parative comfort  if  less  treatment  is  applied  to 


52  Fasting  and  Undernuteition  in 

the  urinary  features  and  more  attention  given 
to  the  physical  individuality  and  idiosyncrasies 
of  the  patient. 

Eule-of-the-thumb  measures  should  certainly 
not  hold  sway  in  the  treatment  of  the  severe  forms 
of  diabetes.  They  should  be  tried,  to  be  sure, 
but  must  not  be  adhered  to  if  they  have  proved 
useless  or  harmful  in  the  particular  instances. 

Apparent  failures 

Apparent  failures  are  not  real  failures.  Many 
of  the  finally  successful  cases  are  failures  in  one 
way  or  the  other  at  the  first  attempts  of  the  fastr 
ing-undernutrition  treatment.  Blame  for  this 
must  mainly  be  given  to  two  causes,  viz.:  first, 
the  lax  manner  in  which  the  fasting-purging- 
rest  program  is  prescribed  and  performed,  and, 
second,  the  too  firm  adherence  to  the  graded 
dietaries  during  the  period  of  undernutrition. 

Ad  1. — In  order  to  adjudge  the  severe  cases  of 
diabetes  properly  and  to  treat  the  suitable  in- 
stances of  the  malady  successfully,  it  is  abso- 
lutely necessary  that  the  attending  physician 
delineate  minutely  every  phase  and  every  step  of 
the  fasting  period  before  the  treatment  is  insti- 
tuted. He  must  have  full  confidence  in  the  com- 
petence and  integrity  of  the  nurse  in  charge  of 
the  case  during  the  inaugural  fast.  The  program 
must  be  strictly  adhered  to  (if  necessary  ten  days 
and  longer),  so  long  as  the  patient  does  not 
alarmingly  fail  in  body  weight,  resistance  and 


The  Treatment  of  Diabetes  53 

strength.  If  this  be  the  case,  fasting  should  be 
discontinued  immediately.  Another  attempt  at  it 
may  be  made  two  or  three  weeks  later.  If  the 
patient  exhibits  then  the  same  alarming  symp- 
toms, fasting  must  again  be  stopped.  Some 
months  later  another  trial  may  be  given.  If 
again  unsuccessful  the  case  belongs  to  the  per- 
emptory failures  and  should  not  be  treated  by 
this  method. 

Ad  2. — ^The  graded  plan  of  undernutrition  as 
outlined  in  the  foregoing,  is  of  course,  only  a 
tentative  one.  It  is  designed  for  the  average  case 
after  the  fasting  period.  It  cannot  in  the  nature 
of  things  be  a  close  fit  in  every  case.  It  is  just 
here  where  individualization  must  set  in.  For 
one  case  the  first  week  of  the  period  of  under- 
nutrition is  too  strenuous,  for  another  the  graded 
dietaries  follow  each  other  too  quickly,  for  a 
third  the  period  of  undernutrition  is  too  ex- 
tended, and  for  a  fourth  and  a  fifth  this  or  that 
is  not  especially  suitable. 

The  various  untoward  phenomena  have  to  be 
met  as  they  arise.  If  in  a  case  the  daily  intake 
of  food  appears  to  be  'too  small  to  keep  body  and 
mind  together — a  not  very  rare  occurrence  in  the 
first  week  after  the  fast — a  somewhat  greater 
amount  may  be  given.  In  many  cases  the  skip- 
ping of  three  or  four  days  of  the  scheduled  diet- 
ary of  the  first  week  makes  no  difference  in  the 
urinary  condition  and  is  of  distinct  advantage  to 
the  general  well-being  of  the  patient.    In  other 


54  Fasting  and  Undernutrition  in 

words,  the  first  week  of  undernutrition  may  often 
be  contracted  to  three  or  four  days.  However,  if 
sugar  reappears,  a  fast  day  should  at  once  re- 
place the  third,  fourth,  etc.,  day,  as  the  case  may 
be,  after  which  one  has  to  start  again  with  the 
dietary  of  the  first  day  following  the  inaugural 
fast. 

In  case  the  diet  of  the  second  week  of  under- 
nutrition should  be  productive  of  urinary  sugar, 
the  food  intake  of  the  previous  week  should  be 
ordered  and  the  patient  kept  on  it  until  the  urine 
has  again  been  sugar-free  for  three  or  four  days. 
If  this  cannot  be  accomplished  in  this  manner  a 
few  fast  days  should  be  intercalated,  after  which 
the  diet  of  the  first  week  is  again  ordered.  Hoav- 
ever,  instead  of  giving  this  diet  for  one  week 
only  it  may  be  necessary  to  continue  it  for  two 
weeks  or  longer.  During  the  time  this  low  diet 
is  taken  the  patient  must  rest  in  bed  for  from 
fourteen  to  eighteen  hours  every  day. 

In  case  a  glycosuria  should  supervene  in  the 
third  week  after  the  fasting  period,  a  fast  day 
should  at  once  be  intercalated  and  the  patient  be 
maintained  on  the  diet  of  the  second  week  of 
undernutrition.  If  this  should  not  render  the 
urine  sugar-free,  another  fast  day  should  be  in- 
tercalated and  the  diet  of  the  first  week  of  under- 
nutrition given  thereafter.  Following  this  the 
food  of  the  second  week  of  undernutrition  is 
given  for  two  weeks  or  longer.  When  the  urine 
is  then  free  from  sugar,  the  diet  of  the  third 


The  Treatment  of  Diabetes  55 

week  of  undernutrition  may  be  permitted.  In 
short,  whenever  sugar  reappears  in  the  urine, 
the  patient  may  be  rendered  sugar-free  by  fast- 
ing and  kept  sugar-free  by  the  prolonged  pursu- 
ing of  the  diet  of  the  week  of  undernutrition  pre- 
ceding the  week  during  which  the  sugar  had  again 
been  excreted. 

None  of  the  apparent  failures  are  real  failures. 
In  nearly  every  pertaining  case  it  is  only  a  ques- 
tion of  time  that  the  desired  object  will  be  at- 
tained. True,  in  some  of  these  cases  the  car- 
bohydrate tolerance  will  always  remain  extremely 
low.  In  such  cases  fats,  proteins  and  vegetables 
with  low  carbohydrate  content— the  diet  of  the 
second  week  of  undernutrition  with  additional 
fats  and  proteins — must  be  given  for  long-con- 
tinued periods. 


56  Fasting  and  Undernutrition  in 


Physico-Therapeutic  Measures  in  the  Manage- 
ment OF  Severe  Forms  of  Diabetes 

With  Especial  Reference  to  the  Fasting  and 
Undernutrition  Periods 

Some  of  the  physical  methods  of  treatment  are 
of  essential  value  in  instances  of  grave  or  ad- 
vanced diabetes.  This  is  especially  the  case  dur- 
ing the  periods  of  fasting  and  undernutrition. 

Rest 

Attention  has  repeatedly  been  drawn  in  pre- 
vious paragraphs  to  the  fact  that  the  diabetic;  pa- 
tient undergoing  fasting  or  undernutrition  needs 
rest  and  much  of  it  at  that.  Eest,  in  fact,  is  the 
sine  qua  non  in  the  management  of  the  severe 
forms  of  diabetes.  It  is  the  most  important  of 
all  physico-therapeutic  measures  during  the  fast- 
ing and  undernutrition  periods.  Appertaining 
details  will  be  found  in  Chapters  II  and  III  of 
this  little  book. 

The  exact  amount  of  rest  needed  in  the  indi- 
vidual case  must  be  left  to  the  common  sense  of 
the  attendant. 

External  temperature 

A  high  surrounding  temperature  is  conducive 
to  the  physical  comfort  and  the  decline  of  the 


The  Treatment  of  Diabetes  57 

glycosuria  in  severe  forms  of  diabetes.  Further- 
more, fasting  and  undernutrition  are  easier  exe- 
cuted in  a  warm  than  in  a  cold  surrounding  at- 
mosphere. One  is  less  hungry  in  a  warm  than  in 
a  cold  climate. 

The  conclusions  are  that  the  fasting-undernu- 
trition  plan  of  treatment  promises  considerable 
success  if  undertaken  during  the  w^arm  seasons 
of  the  year,  that  in  winter  time  the  room  tempera- 
ture should  be  kept  at  summer  heat,  and  that  the 
bed  temperature  should  be  at  or  near  100  deg.  F. 
for  as  long  a  time  as  the  patient  can  tolerate  it. 

To  obtain  the  necessary  bed-warmth,  the  hot- 
water  bag  or  the  electric  heating  pad  must  oc- 
casionally be  resorted  to.  Superheated  air  or  the 
so-called  leukodescent  lamp,  applied  for  the  usual 
brief  periods,  cannot  replace  the  continuously 
warm  surrounding  atmosphere,  and  have  no  spe- 
cial value  as  far  as  the  treatment  of  the  severe 
types  of  diabetes  is  concerned.  Profuse  per- 
spiration, as  induced  by  the  sweat  or  electric  bath 
is,  of  course,  out  of  the  question,  as  it  virtually 
counterworks  the  physiological  objects  which  are 
attained  by  a  moderate  surrounding  temperature. 

During  the  cold  season  patients  with  severe 
diabetes  should  wear  flannels,  at  least  when  out 
of  the  house.  They  may  be  allowed  to  be  in  a 
very  mild  perspiration  for  one  or  two  hours  after 
the  midday  repast.  In  winter  they  should  live 
in  well-ventilated  rooms  heated  to  from  75  to  85 
deg.  F.    While  in  bed,  these  patients  should  be 


58  FaSTIKG   and   UlsTDERNUTRITIOl?   llT 

well-covered  with  blankets,  and  the  temperature 
of  the  room  be  lowered  to  about  65  deg.  F. 

The  utilization  of  an  increased  surrounding 
temperature  in  the  fasting-undernutrition  system 
of  diabetes  treatment  is  based  upon  the  following 
facts  and  observations: 

In  a  paper  read  at  the  Kongress  fiir  innere 
Medizin,  in  April,  1905,  Liithje  brought  out  the 
interesting  fact  that  in  the  grave  diabetes  of  pan- 
creatomized  dogs  the  surrounding  temperature 
had  a  decided  influence  upon  the  intensity  of  the 
glycosuria.  This  was  found  to  be  markedly  de- 
pressed when  the  external  temperature  was  high 
(30  deg.  C.~86  deg.  F.).  He  ascribes  the  in- 
fluence of  the  surrounding  temperature  upon  the 
fluctuation  of  the  sugar  excretion  to  regulatory 
processes  in  connection  mth  the  body  heat,  be- 
cause the  experiment  animal,  exposed  to  the  cold, 
in  the  endeavor  to  maintain  its  momentary  most 
important  function,  the  retention  of  its  body  heat, 
suddenly  excretes  large  amounts  of  sugar.  The 
same  author  also  tried  to  employ  high  external 
temperatures  for  the  treatment  of  human  dia- 
betes. He  had  four  diabetics  under  his  observa- 
tion for  from  one  to  one  and  a  half  months.  Of 
these,  two  cases  were  severe,  one  mild,  and  the 
last  one  moderately  severe.  In  temperatures 
varying  between  15  deg.  and  30  deg.  C.  (43  to 
86  deg.  F.)  he  also  noted  fluctuation  in  the  sugar 
excretion,  but  not  as  marked  as  in  the  dogs. 
Under  the  influence  of  a  high  external  tempera- 


The  Treatment  of  Diabetes  59 

tnre  tolerance  (for  what  is*  not  stated),  body- 
weiglit  and  general  vigor  rapidly  increased. 

In  the  discussion  of  this  paper  Klemperer 
pointed  out  that  the  experiments  of  Liithje 
tended  to  clear  up  some  hitherto  unexplainable 
facts  of 'Clinical  experience.  It  was  kno^\ii  to  him 
for  a  long  time,  he  said,  that  a  cure  at  Carlsbad 
in  winter  did  not  agree  as  well  with  diabetics  as 
one  in  summer,  and  that  the  beneficial  influence 
of  bed-warmth  and  alcohol  upon  grave  cases  of 
diabetes  could  now  also  be  accounted  for.  In  the 
same  discussion  Kiihn  mentioned  the  case  of  a 
patient  living  in  Java  whom  he  found  affected 
with  a  severe  type  of  the  disease,  and  which  he 
had  already  unfavorably  prognosticated  years 
ago.  In  spite  of  the  ingestion  of  large  amounts 
of  carbohydrates  (rice,  etc.),  the  patient  was  still 
alive,  and  Kuhn  concludes  that  the  patient's  pro- 
longed life  may  be  attributable  to  the  relatively 
high  temperature  of  his  abode. 

Busquet  studied  the  influence  of  the  external 
temperature  on  the  intensity  of  the  glycosuria  in 
three  cases  of  diabetes.  His  tests  demonstrated 
conclusively  that  the  glycosuria  constantly  de- 
creased when  the  temperature  surrounding  the 
patients  was  warm,  while  it  increased  when  it  was 
cold.  He  never  placed  his  diabetics  in  tempera- 
tures above  20  deg.  C.  {68  deg.  F.),  but  his  clini- 
cal findings  tallied  with  those  of  Liithje  in  every 
respect. 

At  a  discussion  at  the  meeting  of  the  British 


60  Fasting  and  Undernutrition  in 

Medical  Association  in  1908,  on  diabetes  in  the 
tropics,  attention  was  drawn  to  the  frequent  oc- 
currence of  glycosuria  and  diabetes  in  the  natives 
of  India,  and  to  the  fact  that  acute  cases  are 
rather  infrequently  met  with  in  the  tropics,  where 
the  diabetic  is  not  emaciated  and  his  appetite  less 
abnormal.  Sir  Havelock  Charles  made  the  inter- 
esting statement  that  the  progress  of  the  diabetic 
process  in  the  East  Indian  is  often  slower  than  in 
the  European,  and  that  the  disease  may  last 
twenty-five  years. 

The  foregoing  are  practically  all  the  references 
in  regard  to  the  influence  of  the  external  tem- 
perature on  the  degree  of  the  glycosuria  and  the 
course  of  diabetes  which  I  could  gather  from  a 
brief  search  of  the  literature.  I  have  known  from 
personal  experience  for  a  number  of  years  that 
diabetes  occurring  in  certain  districts  of  Central 
and  South  America,  irrespective  of  a  diet  very 
abundant  in  carbohydrates,  often  runs  a  pro- 
tracted and  very  mild  course.  This  is  also  the 
case  to  some  extent  with  the  diabetic  affection  in 
certain  localities  of  our  own  South.  A  patient 
from  Mississippi,  since  dead  from  old  age  (he 
died  in  the  North),  assured  me  that  he  has  had 
diabetes  for  over  thirty  years.  From  a  number 
of  diabetics,  who  have  repeatedly  come  from  the 
South  to  consult  me,  I  know  that  they  lost  weight 
and  excreted  large  amounts  of  sugar  when  they 
were  in  New  York  for  a  few  weeks,  but  that  their 
body  weight  increased  and  the  glycosuria  de- 


The  Treatment  of  Diabetes  61 

creased  soon  after  they  liad  left  the  flesh  pots  of 
the  North  for  the  hot  corn  and  sweet  potatoes  of 
their  Southern  homes.  Furthermore,  it  is  a  well- 
known  fact  that  rest  in  bed  is  of  beneficial  in- 
fluence in  many  instances  of  grave  diabetes;  the 
good  effect  thus  obtained  is,  however,  universally 
and  solely  credited  to  the  rest  and  not  to  the  bed- 
warmth. 

Without  intending  to  enter  into  statistical  de- 
tails as  regards  my  own  observations  concerning 
the  question  of  surrounding  temperature  and  the 
course  of  glycosuria,  I  wish  to  offer  my  conclu- 
sion on  this  occasion:  (1)  The  external  tempera- 
ture exerts  a  distinct  influence  upon  the  intensity 
of  the  diabetic  glycosuria,  inasmuch  as  this  is  de- 
pressed by  warmth  and  raised  by  cold.  (2)  A 
temperature  of  from  80  to  90  deg.  F.  of  the  sur- 
rounding dry  air  may  be  employed  therapeuti- 
cally to  reduce  the  degree  of  a  diabetic  glycosuria. 
(3)  A  surrounding  temperature  of  from  80  to  90 
deg.  F.  may  'per  se  reduce  the  sugar  output  by 
from  one-fourth  to  one-third.  (4)  A  warm  ex- 
ternal temperature  does  not  materially  influence 
the  ketonuria  concomitant  with  grave  cases  of 
diabetes.  (5)  A  warm  external  temperature  has 
no  noticeable  influence  on  mild  cases  of  diabetes, 
but  exerts  a  salutary  effect  on  moderately  severe 
and  severe  instances  of  the  malady.  (6)  The 
salutary  effects  of  a  w^arm  surrounding  tempera- 
ture on  the  diabetic  organism,  besides  the  reduc- 
tion of  the  glycosuria,  consist  of  the  production 


62  Fasting  and  Undernutrition  in 

of  an  increased  tolerance  for  carbohydrates  and 
proteids ;  tlie  increase  of  body-weiglit,  resistance, 
and  vigor;  the  lessening  of  gastro-intestinal  dis- 
orders, and  the  subduing  of  neuritic  and  angio- 
sclerotic pain. 

Massage 

A  mild  massage  of  the  limbs — five  minutes  for 
each  limb — may  be  daily  practised  in  almost 
every  diabetic  undergoing  the  fasting-undernu- 
trition  treatment.  In  many  cases  the  procedure 
may  be  repeated  on  the  same  day. 

In  cases  after  the  fasting  period  in  which 
there  occurs  much  flatulence  or  in  which  there  is 
a  persistent  non-inflammatory  gastro-intestinal 
disturbance  such  as  a  paretic  condition  of  the 
intestine,  visceral  ptosis  (especially  gastroptosis 
or  coloptosis),  congestive  states,  etc.,  general  ab- 
dominal massage  for  from  fifteen  to  twenty  min- 
utes every  day  is  usually  of  marked  benefit. 

While  massage  is  but  an  accessory  measure  in 
the  treatment  of  the  severer  types  of  diabetes,  it 
should  be  employed  whenever  the  patient's  con- 
dition permits. 

Among  the  physiological  effects  of  massage  the 
mechanical  and  thermal  results  occupy  first 
place.  The  mechanical  effects  supervene  rapidly. 
Cellular  activity  becomes  increased  and  there  en- 
sues an  acceleration  in  the  movement  of  blood  and 
lymph  vessel  contents.  Massage  causes  an  in- 
crease of  the  temperature  of  the  manipulated 


The  Treatment  of  Diabetes  63 

limb.  The  temperature  of  the  whole  body  may 
also  be  elevated  which  is  especially  the  case  after 
abdominal  massage.  Increased  body  heat  causes 
diminution  of  the  glycosuria  intensity  in  nearly 
every  instance.  This  is  also  noticeable  in  many 
febrile  states. 

Walking 

As  soon  as  the  patient  receives  food  yielding 
about  thirty  calories  per  day  and  kilogram  of 
body  weight,  provided  there  be  no  impediment  of 
the  lower  extremities,  he  should  be  instructed  to 
take  short  walks  on  level  ground.  The  length  of 
the  walk  and  its  rapidity  of  necessity  depends 
upon  the  patient's  strength  and  endurance.  He 
should,  however,  not  exceed  one-eighth  of  a  mile 
at  the  first  attempt,  but  he  may  slowly  increase 
his  walk  to  half  a  mile.  As  soon  as  the  patient 
ingests  a  somewhat  larger  amount  of  food  so  that 
about  thirty-five  calories  per  day  and  kilogram 
body  weight  be  furnished,  he  may  take  longer 
walks,  that  is  up  to  about  one  mile.  It  will  be 
found  that  most  diabetics  not  obtaining  a  full 
caloric  supply  are  able  to  walk  from  one  to  two 
miles  every  day  without  any  apparent  effort. 
The  daily  walks  may  be  taken  in  * 'broken  doses.'' 

It  should  be  remembered  that  in  ordinary  walk- 
ing the  work  performed  by  the  muscles  of  the  leg 
is  much  less  than  it  appears  to  be,  since  the  sway- 
ing motion  of  the  leg,  like  the  swinging  of  a  pen- 
dulum, is  a  passive  operation  to  the  greater  part. 


64  Fasting  and  Undernutrition  in 


VI 

Illustrative  Cases 

In  the  following  lines  some  instances  illus- 
trative of  the  fasting-undernutrition  plan  of 
treatment  and  its  results  are  given.  In  these 
case-histories  only  the  data  pertaining  to  the 
fasting-undernutrition  period  which  are  of  the 
most  general  clinical  interest  are  related. 

Case  L — March  20,  1913.  Woman,  forty-one 
years  old;  widow;  has  had  two  children,  both 
dead. 

Diabetes  had  supervened  about  two  years  ago ; 
had  then  weighed  189  pounds.  Present  weight 
145  pounds.  Complains  of  sleeplessness;  head- 
aches; extreme  weakness  and  pains  in  thighs. 

The  physical  examination  showed  very  flabby 
muscles ;  rather  small  liver ;  blood  pressure,  sys- 
tolic, 105  mm.  Hg.  The  urine  showed  the  follow- 
ing features : 

Twenty-four  hours'  amount  2200  c.c;  specific 
gravity  1030;  glucose  12  per  cent.;  acetone 
medium  amount;  diacetic  acid  present;  ammonia 
increased;  albumin  absent;  no  evidence  of  renal 
disease. 

The  patient  was  immediately  ordered  to  go  to 
bed  and  to  fast  for  four  days.  During  this  time 
nothing  but  weak  tea  (without  milk  or  sugar)  and 


The  Treatment  of  Diabetes  65 

water  were  allowed.  The  patient  was  instructed 
to  take  a  tablespoonful  to  a  tablespoonful  and  a 
half  of  Epsom  salts  in  the  evening. 

March  24.  Patient  feels  comfortable.  Urinary 
features:  twenty-four  hours'  amomit  1350  c.c. ; 
specific  gravity  1019;  glucose  absent ,  acetone  in- 
creased; annnonia  stationary. 

March  25.  Still  fasting.  Feels  well.  Urinary 
features:  twenty-four  hours'  amount  1400  c.c. ; 
specific  gravity  1019.5;  glucose  absent;  acetone 
much  increased;  ammonia  increased. 

March  31.  At  my  office.  Feels  stronger ;  slept 
very  well  during  past  w^eek;  has  only  occasional 
headaches;  pains  in  thighs  much  improved. 

Has  been  on  yolk-protein-green  vegetable  diet 
since  breaking  the  fast.  Average  daily  intake 
twenty  calories  for  each  kilogram  body  weight. 
Present  weight  139  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1320  c.c;  specific 
gravity  1016;  glucose  1  per  cent.;  acetone  de- 
creased, 

April  7.  At  my  office.  Feels  decidedly  better ; 
has  uninterrupted  night  rest ;  no  more  headaches ; 
no  longer  pains  in  thighs. 

Has  been  on  about  the  same  diet,  but  some- 
what enlarged  quantities.  Average  daily  intake 
twenty-five  calories  for  each  kilogram  body 
weight.  Present  weight  143%  pounds.  Urinary 
features:  Twenty-four  hours'  amount  1560  c.c; 
specific  gravity  1020;  glucose  1  per  cent.;  acetone 
medium  amount;  ammonia  decreased. 


6Q  Fasting  and  Undernutrition  in 

April  14.  At  my  office.  Feels  strong  and  well ; 
slight  pain  in  thighs.  The  same  diet  as  last  week, 
but  had  in  addition  half  slice  of  toast  in  the  morn- 
ing, half  a  slice  in  the  evening.  Present  weight 
143%  pounds.  Urinary  features:  Twenty-four 
hours'  amount  2800  c.c. ;  specific  gravity  1009; 
glucose  absent;  acetone  absent;  diacetic  acid  ab- 
sent ;  ammonia  normal  amount. 

April  21.  At  my  office.  States  that  she  **feels 
grand";  no  pain  in  thighs;  uninterrupted  night 
rest ;  looks  very  well. 

Has  been  on  the  same  diet,  but  instead  of  half 
a  slice  had  whole  slice  of  toast  in  the  morning  and 
evening.  Present  weight  1431/2  pounds.  Urinary 
features:  Twenty-four  hours'  amount  2000  c.c; 
specific  gravity  1017;  glucose  absent;  acetone 
trace;  no  diacetic  acid;  ammonia  normal  and 
stationary. 

•  April  28.  At  my  office.  Looks  and  feels  well ; 
entirely  free  from  pain;  sleeps  through  entire 
night. 

Has  been  on  the  same  yolk-protein-green  vege- 
table regimen  plus  three  slices  of  toast  per  day. 
Present  weight  143%  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1800  c.c;  specific 
gravity  1014;  glucose  absent;  acetone  absent; 
diacetic  acid  absent;  albumin  absent;  ammonia 
decreased. 

May  5.  At  my  office.  *^ Feels  fine."  Free  from 
pain.    Uninterrupted  sleep  at  night. 

The  same  diet  as  last  week.    Present  weight 


The  Treatment  of  Diabetes  67 

1451/^  pounds.  Urinary  features:  Twenty-four 
hours'  amount  1600  c.c. ;  specific  gravity  1010; 
glucose  0.1  ^per  cent,;  acetone  absent;  diacetic 
acid  absent. 

May  12.  At  my  office.  ''Feels  as  well  as 
ever.'' 

Has  had  the  same  diet,  but  only  two  slices  of 
toast  per  day.  Present  weight  1441/^  pounds. 
Urinary  features:  Twenty-four  hours'  amount 
1750  c.c. ;  specific  gravity  1016 ;  glucose  absent; 
acetone  absent;  diacetic  acid  absent;  no  ammonia 
increase. 

May  26.  'At  my  office.  Feels  and  looks  well. 
Patient  thinks  she  is  cured. 

The  same  diet;  only  two  slices  of  toast  daily. 
Present  weight  147l^  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1750  c.c;  specific 
gravity  1015;  glucose  absent;  acetone  absent; 
diacetic  acid  absent ;  ammonia  in  normal  amounts. 

June  9.    At  my  office.    Feels  and  looks  well. 

The  same  diet ;  three  slices  of  toast  daily.  Pres- 
ent weight  146%  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1750  c.c;  specific 
gravity  1002 ;  glucose  absent;  acetone  and  diacetic 
acid  absent;  albumin  absent;  no  microscopic  evi- 
dence of  any  renal  lesion. 

June  23.    At  my  office.    Looks  and  feels  well. 

The  same  diet ;  three  slices  of  toast  daily.  Pres- 
ent "weight  151%  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1750  c.c;  specific 
gravity  1011 ;  glucose  absent;  acetone  and  diacetic 


68  Fasting  and  Undernutrition  in 

acid  absent;  no  albumin;  no  microscopic  evidence 
of  any  renal  lesion. 

Remarks:  This  case  is  remarkable  inasmuch 
as  there  ensued  a  continuous  increase  in  weight 
despite  a  diet  which  was  not  only  restricted,  but 
the  fuel  value  of  which  never  exceeded  thirty 
calories  per  day  and  kilogram  of  body  weight  for 
any  length  of  time. 

Case  II. — December  28,  1912.  Man,  fifty-one 
years  old,  single.  Theatrical  manager.  Princi- 
pal complaint:  Weakness. 

Diabetes  was  recognized  about  eighteen  months 
ago.  Was  since  under  treatment;  also  was  in 
two  sanitaria.  During  this  period  has  had  as 
much  as  seven  per  cent,  glucose  and  much  ace- 
tone. At  times  the  urine  was  sugar  and  ketone 
free.  Has  lost  about  twenty-five  pounds  in 
weight.  The  physical  examination  revealed  be- 
sides a  much  emaciated  body  and  flabby  muscles 
nothing  that  was  truly  abnormal.  The  heart  was 
not  diseased;  systolic  blood  pressure  140  mm. 
Hg. ;  liver  not  enlarged;  no  abdominal  pressure 
sensitiveness.  Hemoglobin  64  per  cent.  Urinary 
features:  Twenty-four  hours'  amount  1860  c.c; 
specific  gravity  1032;  glucose  8.6  per  cent.;  ace- 
tone very  large  amounts;  diacetic  acid  very  large 
amounts;  ammonia  excessive  amounts;  indican 
absent;  no  microscopic  evidence  of  renal  disease. 

Diet:  The  patient  was  ordered  to  take  a  pro- 
longed fast  under  the  supervision  of  an  experi- 
enced nurse.   Water,  tea  and  Hunyadi  water  were 


The  Treatment  or  Diabetes  69 

to  be  taken  during  the  fast.  After  the  third  fast 
day  40  c.c.  alcohol  (80  c.c.  whiskey)  was  permitted 
during  the  twenty-four  hours. 

Dec.  29.  Feels  well.  Not  very  hungry.  Uri- 
nary  features:  Twenty-four  hours'  amount  1580 
c.c;  specific  gravity  1020;  glucose  absent;  ace- 
tone and  diacetic  acid  very  large  amounts. 

Dec.  30.  Does  not  feel  hungry.  Urinary  fea- 
tures: Twenty-four  hours'  amount  1300  c.c; 
specific  gravity  1017;  glucose  absent;  acetone  and 
diacetic  acid  very  large  amounts.  The  purgative 
upset  the  patient  considerably. 

Dec.   31.     Feels  more   comfortable.     Urinary 
eatures:  Twenty-four  hours'  amount  1220  c.c; 
specific  gravity  1014 ;  glucose  absent;  acetone  and 
diacetic  acid  large  amounts. 

Jan.  1,  1913.  Feels  comfortable.  Urinary  fea- 
tures :  Twenty-four  hours '  amount  900  c.c. ;  speci- 
fic gravity  1008;  glucose  absent;  acetone  and  dia- 
cetic acid  large  amounts.  Patient  was  permitted 
to  take  whiskey  and  in  addition  60  grams  green 
vegetables  with  low  carbohydrate  content. 

Jan.  2.  Feels  comfortable.  Urinary  features: 
Twenty-four  hours'  amount  980  c.c;  specific 
gravity  1018;  glucose  0.83  per  cent.;  acetone  and 
diacetic  acid  large  amounts. 

Jan.  3.    Fasting. 

Jan.  4.    Fasting. 

Jan.  5.  Fasting.  Feels  comfortable,  but  hun- 
gry. Urinary  features:  Tw^enty-four  hours' 
amount  1200  c.c;  specific  gravity  1013;  glucose 


''TO  Fasting  and  Undernutrition  in 

absent;  acetone  and  diacetic  acid  large  amounts. 

The  patient  was  advised  to  remain  in  bed  most 
of  the  time.  Diet:  Exclusion  of  all  starches; 
limited  quantity  of  proteins. 

Jan.  7.  Feels  hungry.  Urinary  features: 
Twenty-four  hours  amount  2000  c.c;  specific 
gravity  1017;  glucose  ahsejit;  acetone  and  dia- 
cetic acid  large  amounts. 

Apenta  water  in  large  doses  was  ordered  to  be 
taken. 

Diet:  Green  vegetables;  fifteen  yolks;  albumin 
of  seven  eggs. 

Jan.  8.  Hunger  is  appeased.  Urinary  fea- 
tures: Twenty-four  hours'  amount  1650  c.c; 
specific  gravity  1022;  glucose  absent;  acetone 
and  diacetic  acid  unchanged  in  amount. 

Jan.  9.  Feels  well.  Same  diet.  Present  weight 
117%  pounds.  Urinary  features:  Twenty-four 
hours'  amount  2350  c.c;  specific  gravity  1018; 
glucose  absent;  acetone  large  amounts. 

Jan.  10.  Patient  was  out  of  the  house  all  day 
yesterday.  Urinary  features:  Twenty-four  hours' 
amount  2300  c.c;  specific  gravity  1014;  glucose 
absent;  acetone  very  small  amount;  diacetic  acid 
absent. 

Jan.  11.  Feels  well.  Urinary  features :  Twenty- 
four  hours'  amount  2000  c.c;  specific  gravity 
1015;  glucose  absent;  acetone  small  amount;  dia- 
cetic acid  absent. 

Diet:  Eighteen  yolks  and  eight  egg  whites 
daily  in  addition  to  green  vegetables. 


The  Treatmext  of  Diabetes  71 

Jan.  12.  Feels  well.  Urinary  features:  T^venty- 
four  lioiirs'  amount  2200  c.c. ;  specific  gravity 
1016;  glucose  absent;  acetone  a  trace. 

Jan.  13.  Feels  well.  Present  weight  118 
pounds.  Urinary  features.  Twenty-four  hours' 
amount  2130  c.c;  specific  gravity  1020;  glucose 
absent;  acetone  and  diacetic  acid  traces. 

Diet:  The  same;  in  addition  180  c.c.  whiskey. 

Jan.  14.  Feels  somewhat  depressed;  pro- 
nounced phosphaturia.  Urinary  features: 
Twenty-four  hours'  amount  2100  c.c;  specific 
gravity  1024;  very  turbid;  large  amounts  of 
earthy  phosphates;  reaction  alkaline;  glucose 
absent;  acetone  mere  trace. 

Jan.  15.  Depressed.  Mouth  temperature  98 
deg.  F.  Present  weight  119%  pounds.  Urinary 
features:  Twenty-four  hours'  amount  2100  c.c; 
specific  gravity  1020;  glucose  absent;  acetone 
trace. 

Patient  was  ordered  to  discontinue  Apenta 
water  for  two  days. 

Diet:  Green  vegetables;  twenty-one  yolks;  ten 
^gg  whites. 

Jan.  16.  Feels  better.  Mouth  temperature 
98.2  deg.  F. ;  pulse  76.  Urinary  features:  Twenty- 
four  hours'  amount  1830  c.c;  specific  gravity 
1020;  glucose  absent;  acetone  and  diacetic  acid 
absent. 

Since  this  time  the  patient  has  not  only  held 
his  o^^Ti,  but  has  gained  about  three  pounds.  His 
urine  is  sugar-free  most  of  the  time;  in  case  he 


72  Fasting  and  Undernutrition  in 

excretes  sugar  this  does  not  exceed  twenty  or 
thirty  grams  in  the  twenty-four  hours.  Ketones 
appear  but  rarely  in  his  urine.  In  other  respects 
the  patient  has  his  ups  and  downs,  but  fasting 
at  proper  intervals  and  long-continued  periods  of 
undernutrition  have  enabled  him  to  devote  all  of 
his  time  to  business  which  is  a  very  extensive 
and  exacting  one.  On  Sundays  he  remains  in 
bed  and  fasts  or  has  but  one  meal  during  the 
twenty-four  hours. 

Case  III. — August  31,  1910.  Man,  forty-nine 
years  old.  Has  had  diabetes  for  about  one  year. 
Complaint:  Shortness  of  breath,  especially  upon 
walking.  No  nocturnal  urination.  No  particular 
weakness.  Decline  of  sexual  desire.  Little  loss 
of  body  weight.  Urinary  features:  Twenty-four 
hours'  amount  1800  c.c. ;  specific  gravity  1022.5; 
glucose  2.5  per  cent.;  acetone  and  diacetic  acid 
absent;  albumin  absent;  indican  absent;  no  mi- 
croscopic evidence  of  renal  disease.  The  case 
was  considered  to  be  of  a  mild  type  and  was  suc- 
cessfully treated  by  the  usual  dietary  means. 

August  7,  1912.  Patient  feels  and  looks  well, 
but  the  diabetic  condition  has  become  aggravated 
to  some  degree.  He  has  lost  about  ten  pounds 
in  body  weight  during  the  last  four  months,  uri- 
nates once  or  twice  during  the  night,  and  the 
twenty-four  hours'  urine  has  increased  to  about 
2500  c.c.  Patient  is  sexually  entirely  impotent. 
He  is  living  in  the  South  and  states  that  he  had 
a  good  deal  of  business  worry  during  the  last  few 


The  Treatment  of  Diabetes  73 

months.  The  urine,  voided  at  my  office,  showed 
a  specific  gravity  of  1024;  glucose  8  per  cent.; 
medium  amounts  of  acetone  and  diacetic  acid  and 
increased  ammonia  output.  The  urine  contained 
no  other  abnormal  substances  or  normal  sub- 
stances in  abnormal  quantity,  and  there  was  no 
evidence  of  any  kidney  lesion. 

The  patient  was  advised  to  undergo  a  thera- 
peutic fast  of  three  or  four  days '  duration.  Dur- 
ing this  period  water  and  tea  were  allowed. 
Castor  oil  was  to  be  taken  before  starting  the 
fast,  and  Epsom  salt,  in  purging  doses,  every  day 
thereafter  during  the  fasting  period.  Rest  in  bed 
was  made  compulsory. 

August  8.  Feels  well.  Urinary  features: 
Twenty-four  hours'  amount  1800  c.c. ;  specific 
gravity  1020;  glucose  2.5  per  cent.;  acetone  and 
diacetic  acid  medium  amounts. 

August  9.  Feels  well.  Urinary  features: 
Twenty-four  hours'  amount  1680  c.c;  specific 
gravity  1015;  glucose  0.2  per  cent.;  acetone  trace; 
diacetic  acid  absent. 

August  10.  Feels  well;  is  not  particularly 
hungry.  Urinary  features:  Twenty-four  hours' 
amount  1400  c.c;  specific  gravity  1013;  glucose 
absent;  acetone  trace;  diacetic  acid  absent, 

August  11.  Feels  comfortable.  Urinary  fea- 
tures: Twenty-four  hours'  amount  1460  c.c;  spe- 
cific gravity  1012.5;  glucose  ahsent;  acetone  and 
diacetic  acid  absent. 

The  patient  was  kept  on  the  graded  plan  of 


74  Fasting  and  Undernutrition  in 

undernutrition  for  three  weeks.  Starcli  in  the 
form  of  toast  was  permitted  thereafter,  at  first 
tentatively,  i,e.,  half  a  slice  twice  a  day.  Later  on 
two  and  three  slices  a  day  were  tolerated.  He 
can  take  now  four  or  five  slices  of  bread  a  day. 
For  one  week  each  month  he  pursues  a  fat-pro- 
tein-vegetable diet  (excluding  cream,  butter, 
cheese  and  vegetables  containing  more  than  five 
per  cent,  available  starch). 

Case  IV.  October  16, 1913.  Man,  52  years  old ; 
Member  of  Congress.  Has  diabetes  for  about  ten 
years.    Complains  of  extreme  weakness. 

A  physical  examination  shows  a  very  dry  skin ; 
fat  heart;  enlarged  liver  and  stomach.  The  lat- 
ter is  also  ptotic.  There  is  no  pressure  point 
sensitiveness.  The  urine  exhibits  a  specific  grav- 
ity of  1030;  glucose  12.5  per  cent.;  some  acetone 
and  diacetic  acid;  no  albumin;  no  indican.  It 
shows  no  microscopic  evidence  of  renal  disease. 

As  the  patient  had  much  declined  in  body 
weight  and  vigor  since  he  was  last  seen  by  me,  a 
three  or  four  days'  fast  w^as  proposed.  The  pa- 
tient readily  consented. 

October  21.  First  fast  day.  Feels  very  well. 
Urinary  features:  Twenty-four  hours'  amount 
2150  CO.;  specific  gravity  1027;  glucose  2.5  per 
cent.;  acetone  trace. 

October  22.  Feels  comfortable.  Not  hungry. 
Urinary  features:  Twenty-four  hours'  amount 
1460  e.c;  specific  gravity  1020;  glucose  0.25  per 
cent.;  acetone  somewhat  increased. 


The  Treatment  of  Diabetes  75 

October  23.  Feels  well.  Not  particularly  hun- 
gry. Urinary  features:  Twenty-four  hours' 
amount  1320  c.c. ;  specific  gravity  1014;  glucose 
absent;  acetone  considerably  increased;  diacetic 
acid  present;  albumin  trace. 

October  24.  Feels  well,  but  rather  weak.  Uri- 
nary features:  Twenty-four  hours'  amount  1550 
c.c. ;  specific  gravity  1014 ;  glucose  absent;  ace- 
tone stationary  in  amount. 

October  25.  Has  lost  over  nine  pounds  during 
the  fast.  Feels  a  little  weak,  but  very  well  other- 
wise.    Institution  of  undernutrition. 

October  27.  Feels  stronger.  Urinary  features: 
Glucose  absent;  acetone  very  small  amount. 

October  31.  Feels  very  well.  Urinary  fea- 
tures: Glucose  absent;  acetone  trace. 

November  5.  Feels  well.  Urinary  features: 
Twenty-four  hours'  amount  1700  c.c;  specific 
gravity  1015;  glucose  absent;  acetone  small 
amount. 

Diet:  Undernutrition  regimen  of  end  of  second 
week;  in  addition  one  slice  of  toast  in  the  morn- 
ing and  evening. 

November  7.  Urinary  features:  Twenty-four 
hours'  amount  1750  c.c;  specific  gravity  1020; 
glucose  absent;  acetone  trace. 

Diet:  The  same,  excepting  two  slices  of  toast 
in  the  morning  and  one  slice  in  the  evening. 

November  10.  Feels  very  well.  Physical  ex- 
amination reveals  nothing  abnormal  of  import. 
Urinary  features:   Twenty-four  hours'   amount 


76  Fasting  and  Undernutrition  in 

1900  c.c. ;  specific  gravity  1018;  glucose  absent; 
acetone  absent. 

Diet:  Undernutrition,  end  of  second  week;  in 
addition  two  slices  of  toast  in  the  morning  and 
evening. 

November  12.  Urinary  features :  Specific  grav- 
ity 1018;  glucose  absent;  acetone  absent. 

The  patient  attends  to  his  arduous  duties  as  a 
member  of  Congress  and  at  home.  He  abstains 
entirely  from  food  for  about  thirty-six  hours 
every  month.  For  one  week  every  month,  follow- 
ing the  fast,  he  adheres  to  the  diet,  prescribed  for 
the  last  days  of  the  second  week  of  the  period  of 
undernutrition.  At  this  time  he  transacts  most 
of  his  business  while  he  is  resting  in  bed.  De- 
spite the  frequent  fasting  and  periods  of  under- 
nutrition the  patient  has  lost  not  more  than  about 
sixteen  pounds  in  thirty-four  months. 

Case  V. — October  9,  1913.  Woman,  fifty-two 
years  old ;  one  child.  Has  had  diabetes  for  fifteen 
years.  States  that  she  was  operated  upon  seven- 
teen times  (fourteen  times  by  one  of  the  most 
renowned  American  gynecologists)  for  genito- 
urinary diseases.    Present  weight  161%  pounds. 

The  physical  examination  reveals  a  distinct 
murmur  (presystolic),  and  a  distinct  accentua- 
tion of  the  second  aortic  sound.  Abdomen  is 
pendulous;  liver  somewhat  enlarged  and  ptotic. 
There  is  an  umbilical  hernia.  No  pressure  point 
sensitiveness.    The  skin  is  full  of  * 'liver  spots" 


The  Treatment  of  Diabetes  77 

of  rather  recent  production.  The  urine  is  voided 
in  daily  amounts  of  about  2000  c.c. 

October  10.  Urinary  features:  Twenty-four 
hours'  amount  1900  c.c;  specific  gravity  1024; 
glucose  7.14  per  cent.;  acetone  medium  amount; 
diacetic  acid  present;  very  turbid;  microscopi- 
cally there  were  distinguished  epithelia  of  lower 
genito-urinary  tract  and  from  renal  pelvis;  pus 
corpuscles;  ammonium  urate  crystals;  colon 
bacilli. 

The  case  was  considered  to  be  one  of  an  ad- 
vanced, though  not  of  a  serious  type  of  diabetes, 
and  a  fast  of  three  days'  duration  was  ordered. 

October  14.  After  the  fast.  Feels  well,  but  is 
very  recalcitrant.  Present  weight  158  pounds. 
Urinary  features:  Twenty-four  hours'  amount 
1200;  specific  gravity  1019;  glucose  0.416  per 
cent.;  acetone  a  trace;  diacetic  acid  absent. 

Diet:  Undernutrition,  first,  second  and  third 
weeks  (yolks,  proteins,  green  vegetables). 

November  4.  Feels  very  well.  Present  weight 
159  pounds.  Urinary  features:  Twenty-four 
hours'  amount  not  stated;  specific  gravity  1024; 
glucose  absent;  acetone  a  trace. 

The  treatment  was  continued  by  the  family 
physician.  Despite  a  rather  large  excretion  of 
sugar  this  case  is  not  of  grave  character.  It  is 
of  long  duration — fifteen  years — at  the  start  of 
the  f  asting-undernutrition  plan  of  treatment.  The 
urinary  anomalies  yielded  readily,  but  the  pa- 


78  Fasting  and  Undernutrition  in 

tient  liad  to  be  watched  very  carefully  as  she  had 
no  self-control  whatever. 

Case  VI.— September  15,  1914.  Man,  fifty-five 
years  old;  attorney-at-law.  Diabetes  was  first 
recognized  in  May,  1914. 

Has  lost  about  thirty  pounds  in  body  weight 
since  the  onset  of  the  affection.  Present  weight 
112%  pounds.  Complains  of  weakness,  rhinitis 
and  extreme  dryness  of  the  mouth  (it  could  be 
demonstrated  later  on  that  this  dryness  was  part 
and  parcel  of  a  very  pronounced  ketonosis).  The 
physical  examination  revealed  a  dry  skin  and 
dry  mucous  membranes,  a  slightly  dilated  heart, 
but  no  other  cardiac  irregularity  of  any  kind. 
The  liver  was  somewhat  enlarged,  more  so  toward 
the  median  line.  It  presented  no  abnormality 
in  hardness,  etc.  The  stomach  was  crowded  to- 
ward the  left;  the  cecum  was  somewhat  inflated. 
No  pressure  point  sensitiveness  anywhere. 

Urinary  features:  Twenty-four  hours'  amount 
2200  c.c. ;  specific  gravity  1026;  glucose  12.5  per 
cent.;  acetone  and  diacetic  acid  very  large 
amounts;  albumin  medium  amount;  microscopic 
evidence  of  sclerotic  kidney. 

Treatment:  Prolonged  fasting;  allowed  during 
the  fast  water,  tea  and  whiskey  (60  c.c.  per  day) ; 
castor  oil. 

September  17.  Feels  about  the  same  as  before 
starting  the  fast.  Urinary  features:  Twenty-four 
hours'  amount  2000  c.c;  specific  gravity  1022; 


The  Treatment  of  Diabetes  79 

glucose  8.33  per  cent.;  acetone  and  diacetic  acid 
very  large  amounts ;  albumin  medium  amount. 

September  18.  Feels  weak,  but  comfortable. 
Urinary  features:  Twenty-four  hours'  amount 
1750  c.c. ;  specific  gravity  1015;  glucose  3.57  per 
cent.  (64.68  grams) ;  acetone  unchanged  in 
amount ;  diacetic  acid  very  large  quantity. 

September  19.  General  condition  unchanged. 
Urinary  features:  Twenty-four  hours'  amount 
2000  c.c;  specific  gravity  1010;  glucose  1.25  per 
cent.;  acetone  and  diacetic  acid  unchanged  in 
amount. 

September  20.  Feels  comfortable.  Urinary 
features:  Twenty-four  hours'  amount  1750  c.c; 
specific  gravity  1008;  glucose  0.9  per  cent.;  ace- 
tone unchanged ;  diacetic  acid  large  amount. 

September  21.  Feels  stronger.  Urinary  fea- 
tures: Twenty-four  hours'  amount  1500  c.c;  spe- 
cific gravity  1007;  glucose  absent;  acetone  de- 
cidedly decreased;  diacetic  acid  traces. 

Patient  refused  to  fast  longer.  Undernutrition 
(yolks-green  vegetables),  about  800  calories  per 
day,  called  forth  a  glucose  output  of  from  15.65 
grams  to  85  grams  per  day  during  the  follomng 
week.  The  ketone  excretion  was  increased,  but 
did  not  reach  then  the  values  which  obtained  be- 
fore the  fast.  Despite  the  continued  excretion  of 
glucose  and  ketones  the  patient  had  reached  about 
120  pounds  in  weight  on  November  4. 

Patient  could  not  again  be  persuaded  to  submit 
to  another  fast  of  the  same  duration.    He  would 


80  Fasting  and  Undernutrition  ik 

execnte  any  other  dietary  stunt.  This,  however, 
proved  without  avail.  Some  time  ago  he  wrote 
me  that  his  urine  was  free  from  sugar  and  ace- 
tone. This,  I  doubt,  unless  he  has  submitted  to 
the  fasting-undernutrition  treatment  since  I  last 
saw  him. 

Case  VII.— May  24,  1906.  Woman,  fifty-three 
years  old;  two  children. 

Diabetes  was  diagnosed  some  years  ago.  Prin- 
cipal complaint  when  first  seen  by  me  was  pruri- 
tus vulvae.  Former  weight  190  pounds;  present 
weight  160^/2  pounds. 

The  case  was  a  rather  mild  one,  belonging  to 
the  type  of  diabetes  of  the  obese.  For  more  than 
eight  years  the  diet  of  the  patient  was  not  rigid, 
the  daily  amount  of  permitted  carbohydrate  vary- 
ing between  100  and  150  grams.  Slowly  the  car- 
bohydrate tolerance  declined  and  ketonuria,  at 
first  more  or  less  intermittent,  ensued.  In  mean- 
time an  ulcus  malum  on  the  right  foot  and  some 
minor  gangrenous  processes,  due  no  doubt  to 
obliterating,  atherosclerotic  changes,  had  formed. 
For  these  various  reasons  the  patient  was  in- 
structed to  undergo  a  fasting-undernutrition 
treatment  in  November,  1914. 

November  4.  (Before  fast)  Urinary  features: 
Twenty- four  hours'  amount  2200  c.c. ;  specific 
gravity  1028;  glucose  3.5  per  cent.  (77  grams); 
acetone  and  diacetic  acid  medium  amounts;  am- 
monia much  increased. 

The  patient  utilizied  a  servant  as  a  nurse  dur- 


The  Treatment  of  Diabetes  81 

ing  the  fast.  Tea,  water  and  Epsom  salts  were 
taken  in  the  usual  amounts.  Alcohol  was  refused 
by  the  patient. 

November  8.  After  three  days'  fast.  Patient 
feels  well;  is  not  particularly  hungry.  Urinary 
features:  Twenty-four  hours'  amount  1200  c.c. ; 
specific  gravity  1020;  glucose  one  per  cent.  (12 
grams).  Acetone  and  diacetic  acid  small 
amounts. 

Slough  of  gangrenous  processes  decidedly  less 
(proper  local  treatment  was  applied  all  the  time). 

November  11.  After  six  and  one-half  days' 
fast.  Feels  very  comfortable ;  not  hungry  and  not 
** really  weak."  Urinary  features:  Twenty-four 
hours'  amount  1000  c.c;  specific  gravity  1020; 
glucose  absent;  acetone  and  diacetic  acid  absent. 

The  patient  was  thereafter  kept  on  the  afore- 
described  graded  plan  of  undernutrition.  The 
urine  remained  sugar  and  ketone-free  for  a  num- 
ber of  months.  Weekly  fast  days  were  inter- 
calated for  some  time.  During  the  summer  of 
1915  the  patient  relaxed  somewhat  in  her  regime 
with  the  result  that  the  pathological  urinary  fea- 
tures became  aggravated.  The  patient  has  since 
been  subjected  to  a  series  of  fasting  periods ;  the 
outcome  proved  always  beneficial.  The  various 
gangrenous  processes  have  entirely  healed.  (The 
patient  has  received  for  the  latter  not  alone  the 
proper  antiseptic  applications  and  surgical  treat- 
ment, but  also  footbaths  of  sodium  salicylate, 
superheated  air,  etc.)     The  healing  of  these  gan- 


82  Fasting  and  Undernutrition  in 

grenons  mortifications  must  be,  in  part  at  least, 
ascribed  to  the  dietary  inflnences. 

Case  VIII. — March  24,  1915.  Woman,  forty 
years  old;  two  children. 

Diabetic  symptoms  are  present  for  abont  two 
years.  Former  weight  145  pounds;  present 
weight  115  pounds.  Is  lean,  but  quite  energetic. 
Attends  to  her  affairs,  but  is  often  very  tired  and 
exhausted.  Has  noted  decline  of  sexual  appetite. 
Complains  especially  of  interstitial  gingivitis. 
The  physical  examination  revealed  an  emaciated 
body  with  extremely  dry  external  integument. 
No  cardiac  lesion.  Blood  pressure,  systolic,  120 
mm.  Hg.  Liver  somewhat  enlarged.  No  pressure 
point  sensitiveness  anywhere.  Deep  reflexes 
slightly  exaggerated.  Wassermann  negative. 
The  urine  showed  the  following  features :  Twenty- 
four  hours'  amount  2100  c.c;  specific  gravity 
1034;  glucose  20  per  cent.  (420  grams);  acetone 
and  diacetic  acid  large  amounts;  ammonia  in- 
creased ;  albumin  absent ;  no  microscopic  evidence 
of  renal  disease.  Patient  is  under  a  very  liberal 
diet  which  has  been  prescribed  by  the  family 
physician.  Partakes  of  plenty  of  milk,  cream, 
bread  and  fruit,  I  ordered  a  fat-protein-green 
vegetable  diet  plus  two  slices  of  toast  per  day. 

March  29.  Patient  feels  somewhat  stronger. 
Present  weight  109  pounds.  Urinary  features: 
Twenty-four  hours'  amount  2000  c.c;  specific 
gravity  1030;  glucose  5  per  cent  (100  grams); 


The  Treatment  of  Diabetes  83 

acetone  much  reduced;  diacetic  acid  unchanged; 
ammonia  stationary;  no  indican;  no  albumin. 

Diet:  The  same,  but  three  instead  of  two  slices 
of  toast  per  day. 

April  1.  Is  somewhat  stronger.  Urinary  fea- 
tures: Twenty-four  hours'  amount  1920  c.c. ; 
specific  gravity  1040;  glucose  10  per  cent.  (192 
grams);  acetone  increased;  diacetic  acid  un- 
changed; ammonia  slightly  increased;  albumin 
and  indican  absent. 

Diet:  The  same,  excepting  toast.  As  only  car- 
bohydrate rice,  30  grams,  boiled,  in  morning,  30 
grams  in  evening. 

April  8.  Feels  very  weak.  Urinary  features: 
Twenty-four  hours*  amount  2000  c.c;  specific 
gravity  1030;  glucose  5  per  cent.  (100  grams); 
acetone  decreased ;  diacetic  acid  absent ;  ammonia 
much  decreased;  albumin  and  indican  absent. 

Diet:  The  same;  increased  amount  of  yolks. 
To  add  sodium  bicarbonate  in  large  doses. 

April  14.  Looks  and  feels  better.  Has  passed 
large  amounts  of  earthy  phosphates  during  last 
few  days.  Urinary  features :  Twenty-four  hours ' 
amount  2100  c.c;  specific  gravity  1030;  glucose 
5  per  cent. ;  acetone  much  increased ;  diacetic  acid 
present;  ammonia  increased;  indican  and  albu- 
min absent.  Yolks  and  sodium  bicarbonate  with- 
out avail  in  reducing  ketone  substances. 

Diet:  The  same,  however,  instead  of  rice  oat- 
meal in  the  same  quantity. 


84  Fasting  and  Undernutrition  in 

April  21.  Feels  better  and  much  stronger. 
Present  weight  107%  pounds.  Urinary  features: 
Twenty-four  hours'  amount  1850  c.c. ;  specific 
gravity  1030;  glucose  5  per  cent.  (92.5  grams); 
acetone  large  amount;  diacetic  acid  medium 
amount;  ammonia  increased;  indican  and  albu- 
min absent. 

Diet:  The  same ;  30  grams  oatmeal  in  the  morn- 
ing; 30  grams  in  the  evening. 

April  28.  Feels  better  and  stronger.  Has 
taken  much  water  and  perspired  profusely  (hot 
weather) ;  has  ingested  from  seventeen  to  twenty 
yolks  (six  whole  eggs)  per  day.  Present  weight 
110%  pounds.  Urinary  features:  Twenty-four 
hours'  amount  3000  c.c;  specific  gravity  1034; 
glucose  7  per  cent.  (210  grams) ;  acetone  large 
amounts;  diacetic  acid  unchanged;  ammonia  in- 
creased; albumin  and  indican  absent. 

Diet:  The  same,  including  the  large  amount  of 
yolks.  Under  this  plan  of  treatment  the  patient 
held  her  own  until  the  beginning  of  October,  when 
her  weight  had  declined  to  107  pounds.  The 
urine  during  this  period  always  contained  be- 
tween three  and  eight  per  cent,  of  sugar,  and  was 
not  ketone-free  on  a  single  occasion.  After  oat- 
meal as  '^sole  carbohydrate"  had  been  taken  for 
some  months  it  was  replaced  by  potatoes.  When 
potatoes  as  the  sole  carbohydrate  were  ingested 
(three  per  day)  the  glucose  output  never  ex- 
ceeded 5  per  cent.,  and  the  twenty-four  hours' 
urine  did  not  exceed  1800  c.c.    Hence  never  mor^ 


The  Treatment  of  Diabetes  85 

than  90  grams  glucose  were  excreted  on  any  of 
the  potato  days. 

In  order  to  render  the  patient  sugar-free  and, 
if  possible,  also  ketone-free,  a  fasting  period 
under  the  supervision  of  an  experienced  attend- 
ant was  ordered  on  October  10.  The  patient  was 
instructed  to  go  to  bed  and  stay  there  during  the 
entire  period  of  fasting,  to  take  medium  doses 
of  Epsom  salts  every  day,  and  water  or  tea  when 
desired.  "Whiskey  not  to  exceed  60  c.c.  per  day 
was  allowed  to  be  taken  in  broken  doses.  It  was 
advised  to  take  resort  to  the  electric  pad  in  case 
the  patient  felt  slightly  chilled. 

October  11.  Patient  is  comfortable  and  does 
not  complain  of  hunger.  Has  slept  three  hours 
in  the  afternoon  and  nearly  through  the  night. 
Had  two  copious  movements  after  taking  mag- 
nesium sulphate.  Eectal  temperature  at  8  A.M. 
99  deg.  F. ;  pulse  90 ;  respiration  20 ;  rectal  tem- 
perature at  4  P.M.  98.6  deg.  F. ;  pulse  92 ;  respira- 
tion 20.  Intake  of  liquids  during  twenty-four 
hours  1200  c.c.  Urinary/  features:  Twenty-four 
hours'  amount  630  c.c;  specific  gravity  1018; 
glucose  1.86  per  cent.  (11.71  grams);  acetone, 
diacetic  acid  and  ammonia  diminished. 

October  12.  Patient  is  comfortable  and  does 
not  complain  of  hunger.  Has  slept  well.  Eectal 
temperature  at  8  A.M.  99.2  deg.  F.;  pulse  100; 
respiration  20 ;  rectal  temperature  at  4  P.M.  98.4 
deg.  F.;  pulse  88;  respiration  20.  Intake  of 
liquids  during  last  twenty-four  hours  900  c.c; 


86  Fasting  and  Undernutrition  in 

urine  twenty-four  hours  amount  630  c.c.  Other 
urinary  features:  Specific  gravity  1015;  glucose 
absent;  acetone  and  diacetic  acid  absent;  ammonia 
diminished. 

The  fast  was  continued  for  four  days  longer, 
during  which  time  the  urine  remained  free  from 
sugar  and  ketones.  The  plan  of  undernutrition 
treatment  was  started  on  October  17.  The  urine 
on  this  date  showed  neither  sugar  nor  ketones. 
On  October  24,  when  the  urine  was  still  free  from 
sugar  and  ketones,  the  second  week  of  under- 
nutrition was  started.  The  food  w^hich  the  pa- 
tient then  obtained  yielded  from  about  1000  to 
1100  available  calories  per  day. 

October  27.  The  patient  feels  well,  but  has 
slightly  lost  in  weight.  The  urine  is  free  from 
sugar  and  ketones. 

November  24.  After  a  two-weeks'  stay  at  At- 
lantic City,  during  which  time  the  patient  had 
more  or  less  overstepped  the  undernutrition 
boundaries,  she  feels  and  looks  well.  Urinary 
features:  Twenty-four  hours'  amount  1600  c.c; 
specific  gravity  1029 ;  glucose  2.86  per  cent.  (45.76 
grams) ;  acetone  and  diacetic  acid  medium 
amounts;  albumin  absent. 

Fasting  period  ordered.  Tea  and  water  al- 
lowed; alcohol  permitted  in  amounts  of  from  40 
to  60  c.c.  (from  80  to  120  c.c.  whiskey)  per  day. 
Epsom  salts.    No  attending  nurse. 

November  28.  After  fasting  three  and  one- 
half  days.    Feels  well  and  not  hungry.    Urinary 


The  Treatment  of  Diabetes  87 

features:  Twenty-four  hours'  amount  850  c.c. ; 
specific  gravity  1015;  glucose  absent;  acetone 
trace;  diacetic  acid  absent, 

December  1.  After  six  days  of  fasting.  Feels 
well.  Urinary  features:  Twenty-four  hours' 
amount  800  c.c;  specific  gravity  1015;  glucose 
absent;  acetone  small  amount;  diacetic  acid  small 
amount. 

December  3.  After  eight  days  of  fasting.  Pa- 
tient feels  well.  Urinary  features:  Twenty- four 
hours'  amount  800  c.c;  specific  gravity  1012; 
glucose  absent;  acetone  slightly  increased;  dia- 
cetic acid  slightly  increased ;  ammonia  increased ; 
albumin  and  indican  absent. 

The  following  diet  (undernutrition)  was  or- 
dered: Breakfast — two  soft  boiled  eggs,  cup  of 
tea  without"  milk  or  sugar ;  10  A.M. — 15  c.c  whis- 
key; luncheon — two  cups  of  bouillon,  soup-plate- 
ful of  spinach  or  string  beans,  green  salad;  2 
P.M.  15  c.c.  whiskey;  4  P.M.  cup  of  tea  without 
milk  or  sugar;  supper — bouillon,  one  egg,  soup- 
plateful  of  green  vegetables,  green  salad ;  8  P.M. 
15  c.c  whiskey. 

December  10.  Has  strictly  complied  with  diet. 
Feels  well.  Urinary  features:  Twenty-four 
hours'  amount  1100  c.c;  specific  gravity  1025; 
glucose  1  per  cent.  (11  grams) ;  acetone  and  dia- 
cetic acid  small  amount. 

Diet:  The  same;  in  addition  six  more  yolks  to 
the  daily  ration.  To  walk  one-half  mile  daily  if 
weather  permits. 


88  Fasting  and  Undernutrition  in 

December  17.  Looks  well.  States  that  slie  feels 
very  hungry.  Present  weight  102  pounds.  Uri- 
nary features:  Twenty-four  hours'  amount  1000 
c.c. ;  specific  gravity  1020;  glucose  absent;  ace- 
tone and  diacetic  acid  absent. 

The  patient  weighs  now  in  the  neighborhood 
of  111  pounds.  She  feels  very  well  and  energetic 
and  attends  to  most  of  her  household  duties.  She 
is  sugar-free  most  of  the  time.  The  few  times 
she  excreted  sugar  during  the  last  eight  months 
the  daily  amount  never  exceeded  five  or  six 
grams.  On  no  occasion  has  the  patient  excreted 
acetone  or  diacetic  acid  since  her  improvement 
last  December. 

The  patient  is  now  very  well  able  to  manage 
her  own  case.  As  a  rule  she  fasts  one  day  every 
week;  occasionally  she  only  fasts  for  one  day 
every  second  week.  She  obtains  about  thirty 
calories  per  day  and  kilogram.  The  food  is  al- 
most entirely  absorbable.  She  never  ingests  less 
than  ten  yolks  per  day.  Besides  the  starches 
yielded  by  green  vegetables  she  also  obtains 
about  30  grams  of  starch  a  day  in  the  form  of 
toast.  A  small  amount  of  water  or  muskmelon 
was  permitted  of  late. 

This  case  is  one  of  the  most  interesting  ones 
which  I  had  the  good  fortune  to  observe.  For 
this  reason  I  have  reported  it  somewhat  in  detail. 
It  clearly  demonstrates  the  great  value  of  fasting 
and  undernutrition  in  suitable  cases.  This  case 
was,  and  probably  still  is,  a  very  grave  instance 


The  Treatment  of  Diabetes  89 

of  diabetic  deterioration.  The  patient  was  treated 
on  *^ new-fashioned/'  liberal  lines  by  her  family 
physician,  which  aggravated  the  disease  without 
any  doubt.  For  nearly  seven  months  I  tried  to 
render  the  patient  sugar-  and  ketone-free  by  the 
older  methods  of  dieting  without  any  assured 
success.  Within  a  few  weeks  from  the  start  of 
the  inaugural  fast  the  entire  type  of  the  affection 
of  this  patient  seemed  to  have  changed. 

Case  IX.— July  28,  1915.  Man,  thirty-eight 
years  old.  Had  indigestion  for  years;  obtained 
life  insurance  policy  two  and  a  half  years  ago. 
In  December,  1914,  had  colicky  pains  and  was 
operated  upon  for  appendicitis.  Four  days  after 
the  operation  had  a  ^  ^  stroke  of  paralysis, ' '  viz. : 
face  Vv^as  dra^^ai  to  one  side;  had  aphonia;  could 
not  write  with  right  hand;  had  frontal  headache 
for  two  weeks.  He  could  speak  in  whispers  after 
about  two  weeks  and  at  about  the  same  time  there 
ensued  a  corresponding  improvement  in  the  right 
arm.  Sugar  was  found  in  patient  ^s  urine  shortly 
after  the  operation;  acetone  was  also  demon- 
strated on  some  occasions.  Complains  of  noc- 
turnal urinations  and  absence  of  sexual  desire. 
Speaks  very  deliberately.  Intonation  is  very 
monotonous. 

The  examination  showed  the  follomng:  Heart, 

weak  impulse ;  no  valvular  or  myocardial  disease ; 

,  slight  accentuation  of  pulmonic  and  aortic  second 

sounds;   blood   pressure,    systolic,    95   mm.    Hg. 

Liver  is  somewhat  enlarged;  freely  palpable  on 


90  Fasting  and  Undernutrition  in 

deep  inspiration;  stomacli  normal  in  size;  pres- 
sure point  sensitiveness  in  lower  epigastric  re- 
gion; intestines  apparently  not  abnormal;  cecnm 
somewhat  enlarged.  Deep  reflexes  normal;  anes- 
thetic zones  over  portions  of  right  arm;  coordina- 
tion and  accommodation  fair;  pupillary  reflexes 
somewhat  sluggish.  Wassermann  test  negative; 
cerebrospinal  fluid  negative.  Urinary  features: 
Twenty-four  hours'  amount  2600  c.c. ;  specific 
gravity  1034;  glucose  16  per  cent.  (335.6  grams) ; 
acetone  and  diacetic  acid  large  amounts. 

Diet:   Fat-protein-green  vegetables. 

July  31.  Feels  weak  and  tired  out;  nocturnal 
micturition.  Urinary  features:  Twenty-four 
hours'  amount  1800  c.c;  specific  gravity  1027; 
glucose  8.66  per  cent.  (155.85  grams) ;  acetone 
and  diacetic  acid  large  amounts. 

Diet:  Unchanged. 

August  2.  Feels  very  weak.  No  nocturnal 
micturition.  Urinary  features:  Twenty-four 
hours'  amount  2000  c.c;  specific  gravity  1030; 
glucose  4  per  cent.  (80  grams) ;  acetone  un- 
changed in  amount. 

August  4.  Feels  very  weak;  has  lost  seven 
pounds  since  dieting.  Urinary  features:  Twenty- 
four  hours'  amount  1560  c.c;  glucose  0.25  per 
cent.  (3.19  grams);  acetone  very  large  amount; 
diacetic  acid  ditto. 

August  5.  Still  weak.  Urinary  features: 
Twenty-four  hours'   amount   1500   c.c;   specific 


The  Treatment  of  Diabetes  91 

gravity  1016;  glucose  absent;  acetone  and  dia- 
cetic  acid  medium  amounts. 

August  6.  Is  stronger,  but  complains  of 
cramps  in  epigastric  region.  Urinary  features: 
Twenty-four  hours'  amount  1620  c.c. ;  specific 
gravity  1023;  glucose  absent;  acetone  and  dia- 
cetic  acid  medium  amounts. 

Diet:  Unchanged. 

August  7.  Feels  stronger.  Complains  of 
watery  stools.  Urinary  features:  Twenty-four 
hours'  amount  900  c.c;  specific  gravity  1030; 
glucose  0.5  per  cent.  (4.5  grams) ;  acetone  and 
diacetic  acid  medium  amounts. 

August  9.  Feels  very  weak.  Bowels  were  not 
evacuated  for  two  days.  Examination  of  the  epi- 
gastrium and  neighboring  regions  shows  nothing 
abnormal.  Liver  is  somewhat  enlarged,  espe- 
cially toward  left.  This  may  be  due  to  the  head 
of  the  pancreas.  There  is  no  pressure  pain  in 
pancreatic  region  or  anywhere  else  in  abdomen. 
Urinary  features:  Twenty-four  hours'  amount 
1360  c.c;  specific  gravity  1029;  glucose  1.25  per 
cent.  (17  grams);  acetone  medium  amount;  dia- 
cetic acid  small  amount;  albumin  and  indican 
absent;  no  microscopic  evidence  of  renal  irri- 
tation. 

Diet:  Unchanged. 

August  10.  Feels  better.  Urinary  features: 
Twenty-four  hours'  amount  not  ascertained;  spe- 
cific gravity  1025 ;  glucose  absent ;  acetone  medium 
amount. 


92  Fasting  and  TJndernutkition  in 

In  order  to  detoxicate  the  patient  and  to  ren- 
der him,  if  possible,  ketone-free,  a  fasting  period 
of  four  days  and  complete  rest  in  bed  were  or- 
dered. During  the  fast  Epsom  salts  in  sufficient 
doses  was  to  be  taken  every  day.  Tea  and  water 
were  allowed  as  much  as  desired. 

August  14.  After  a  fast  of  four  entire  days. 
Feels  very  comfortable;  is  not  particularly  hun- 
gry; has  perspired  during  the  entire  time.  Uri- 
nary features:  Twenty-four  hours'  amount  900 
c.c. ;  specific  gravity  1020;  glucose  absent;  ace- 
tone and  diacetic  acid  absent;  ammonia  normal 
amount. 

Diet:  The  same  as  prior  to  the  fast  (undernu- 
trition). 

August  16.  Does  not  feel  very  strong.  Uri- 
nary features:  Twenty-four  hours'  amount  1350 
and  diacetic  acid  absent. 

Inasmuch  as  the  patient  is  compelled  to  return 
to  his  home  in  Utah  within  the  next  forty-eight 
hours,  some  toast  (half  a  slice  at  noon  and  half 
a  slice  in  the  evening)  is  added  to  his  diet. 

August  17.  Feels  better.  Urinary  features: 
Twenty-four  hours'  amount  1300  c.c;  specific 
gravity  1025;  glucose  absent;  acetone  and  dia- 
cetic acid  absent. 

Diet:  The  same,  but  instead  of  half  a  slice  one 
whole  slice  of  toast  to  be  added  to  the  midday 
and  evening  meals. 

August  18.  Feels  better.  Has  gained  nearly 
two  pounds  in  body  weight.     Urinary  features: 


The  Treatment  of  Diabetes  93 

Twenty-four  hours'  amount  1320  c.c. ;  specific 
gravity  1023;  glucose  absent;  acetone  and  dia- 
cetic  acid  absent. 

This  case  is  interesting  for  the  fact  that  under- 
nutrition could  not  suppress  ketonosis  while  fast- 
ing for  a  few  days  freed  the  system  from  acetone 
and  its  mother  substance.  The  influence  of  un- 
dernutrition was  not  sufficiently  strong  and  far- 
reaching.  In  other  instances  fasting  is  apt  to 
aggravate  an  existing  ketonuria. 


PART    II 


SUPPLEMENTARY  NOTES  ON  THE  TOPIC 

OF  THE  KETONES  IN  THE  HUMAN 

ORGANISM 

In  the  following  the  ketone  (acetone)  question 
is  dealt  with  somewhat  in  detail.  Particular 
stress  is  laid  upon  the  mode  of  production  of  the 
acetone  bodies  in  the  human  organism  and  the 
rationale  of  the  ^*yolk  cure''  in  the  suppression 
of  these  substances.  Again,  some  material  has 
been  added  that  will  facilitate  the  understanding 
of  the  mooted  question  in  its  broader  bearings. 
Without  a  careful  reading  of  these  supplemen- 
tary notes  much  that  has  been  said  in  the  pre- 
vious chapters  cannot  be  fully  comprehended. 


The  Acetone  Bodies  in  the  Urine  and  the 
Ferric  Chlorid  Reaction 

It  has  become  a  matter  of  routine  with  many 
to  employ  the  ferric  chlorid  reaction  when  ex- 
amining diabetic  urines  and  to  depend  upon  it 
for  the  recognition  of  diabetic  acidosis.  Clinical 
reports  nowadays  found  in  American  as  well  as 
in  foreign  literature,  in  which  apparently  sole 
reliance  upon  the  ferric  chlorid  reaction  for  the 

91 


98  Fasting  and  Undernutrition  in 

detection  of  diabetic  acidosis  has  been  placed,  are 
becoming  so  numerous,  that  a  word  of  caution  as 
regards  the  insufficient  mode  of  testing  is  cer- 
tainly in  order. 

The  acetone  bodies  —  beta  -  oxybutyric  acid, 
aceto-acetic  acid  (diacetic  acid)  and  acetone — are 
interrelated,  it  is  true,  and  are  derived  by  suc- 
cessive processes  of  oxidation  from  their  common 
progenitors:  the  caproic,  valerianic  and  butyric 
acids.  However,  contrary  to  a  general  supposi- 
tion, the  three  acetone  bodies  do  not  always  co- 
exist and  never  occur  in  a  definite  ratio  to  each 
other.  Acetone  is  the  least  important  substance 
of  this  group,  while  beta-oxybutyric  acid  repre- 
sents the  most  dangerous  factor  of  acidosis.  This 
at  least  is  the  opinion  prevailing  at  the  present 
day.  As  a  matter  of  fact,  only  a  small  portion 
of  the  acetone  occurs  as  such  in  the  urine;  the 
greater  amount  is  yielded  by  the  aceto-acetic  acid 
(diacetic  acid)  on  standing  of  the  urine  or  when 
the  reagents  are  added.  In  reality  an  acetonuria 
is  therefore  a  diaceturia. 

Aceto-acetic  acid  (diacetic  acid)  is  the  only 
acetone  body  giving  the  ferric  chlorid  reaction. 
While  the  reaction  is  obtained  in  most  instances 
of  diabetic  acidosis,  there  is  a  certain  proportion 
of  cases  in  which  it  does  not  ensue,  at  least  not 
on  all  occasions.  "When  a  diabetic  urine  is  being 
accumulated  for  twenty-four  hours  for  the  glu- 
cose determination — a  common  and  necessary 
practice — ^its  diacetic  acid  may  have  become  com- 


The  Treatment  of  Diabetes  99 

pletely  oxidized  to  acetone  at  the  time  of  examina- 
tion. To  avoid  this  eventuality  only  freshly 
voided  diabetic  urines  should  be  subjected  to  the 
ferric  chlorid  test.  Diabetic  urines  which  have 
been  standing  for  a  number  of  hours  must  be 
examined  for  acetone  by  one  of  the  direct  acetone 
tests,  preferabl}^  by  the  sodium — nitroprussiate — 
potassium  hydroxid — acetic  acid — method  (Le- 
gal's  test). 

Beta-oxybutyric  acid,  one  of  the  paramount  acid 
factors  in  diabetic  acidosis,  is  not  always  found  in 
the  urine  associated  with  the  other  acetone  bodies. 
This  is  especially  the  case  in  far  advanced  in- 
stances of  acid  intoxication  when  the  oxidative 
qualities  of  the  diabetic  organism  are  interfered 
mth  to  such  an  extent  that  beta-oxybutyric  acid 
virtually  represents  the  last  stage  of  the  oxy- 
transformation  of  aforementioned  fatty  acids  of 
low  molecular  weight.  Of  course,  the  ferric 
chlorid  test  w^ill  not  respond  if  beta-oxybutyric 
acid  is  the  sole  representative  of  the  acetone 
group  and  the  tests  for  acetone  as  such  mil  like- 
mse  be  negative.  Inasmuch  as  we  do  not  possess 
a  simple  reaction  for  the  detection  of  beta-oxy- 
butyric acid  this  is  never  searched  for  by  the 
practitioner,  and  many  a  case  of  acidosis  occur- 
ring at  the  time  of  examination  without  the  lower 
homologues  of  oxybutyric  acid  simply  remains 
unrecognized,  and  this  at  a  period  when  vigorous 
treatment  is  especially  indicated. 

In  pronounced  instances  of  diabetic  acidosis 


100         Fasting  and  Undernutrition  in 

when  oxybutyric  acid  exists  in  large  amounts  in 
the  urine,  especially  when  it  be  associated  with 
some  butyric  acid,  its  immediate  progenitor — as 
is  not  infrequently  the  case — its  presence  can 
always  be  readily  detected  by  its  penetrating 
rancid  odor. 
To  summarize: 

1.  A  positive  ferric  chlorid  reaction  is  usually 
indicative  of  a  state  of  acidosis,  but  the  reaction 
is  solely  due  to  the  presence  of  aceto-acetic  acid 
(diacetic  acid). 

2.  A  negative  ferric  chlorid  reaction  does  not 
preclude  the  presence  of  either  oxybutyric  acid  or 
acetone. 

3.  The  ferric  chlorid  test  should  be  applied  to 
the  freshly  voided  urine  only,  as  the  entire  aceto- 
acetic  acid  or  a  portion  of  it,  by  a  loss  of  CO2, 
may  be  converted  into  acetone  if  the  urine  be 
standing  for  some  time. 

4.  As  a  rule,  no  acetone  at  all,  or  only  a  small 
amount  of  it  exists  in  a  preformed  state  in  the 
freshly  voided  native  urine.  Standing  of  the 
urine  or  reagents  causes  liberation  of  acetone 
from  aceto-acetic  acid. 

5.  The  presence  of  aceto-acetic  acid  or  of 
aceto-acetic  acid  and  acetone  does  not  of  neces- 
sity point  to  the  occurrence  in  clinical  amounts 
of  beta-oxybutyric  acid. 

6.  Oxybutyric  acid  is  one  of  the  paramount 
acid  factors  of  diabetic  acidosis  so  far  as  we  know 
at  the  present  day. 


The  Treatment  of  Diabetes  101 

7.  Oxybutyric  acid  which  is  not  demonstrable 
by  the  simpler  testing  methods  may  be  readily 
discerned  by  its  rancid  odor. 

8.  A  direct  search  should  invariably  be  made 
for  acetone  by  one  of  the  other  acetone  tests. 


II 

Ake  There  Ketones  of  Intestinal  Production? 

This  chapter  simply  deals  with  the  almost  for- 
gotten question: — Are  some  of  the  ketones  of 
enterogenous  formation?  Acidosis,  as  such,  is, 
therefore,  only  mentioned  in  a  casual  way. 

In  many  cases  of  acidosis  beta-oxybutyric  acid 
is  found  in  excessive  amounts.  However,  it  is  by 
no  means  the  only  low  fatty  acid  that  contributes 
toward  the  acid  intoxication.  The  other  members 
of  this  series — proprionic,  valeric,  capric,  enan- 
thylic,  caprylic,  pelargonic  and  caproic  acids  are 
probably  as  important  in  the  production  of 
acidosis  as  are  the  members  of  the  butyric  acid 
group  themselves.  Furthermore,  besides  acetone 
(CsHgO),  the  ketone  yielded  by  acetic  or  aceto- 
acetic  acid,  the  ketones  formed  from  the  succes- 
sive members  of  the  fatty  acid  series,  differing 
from  one  another  by  t^\dce  CH2,  undoubtedly  par- 
ticipate in  the  production,  or  are  concomitants  of 
the  clinical  pictures  that  are  erroneously  ascribed 
to  the  acetone  bodies  or  their  direct  progenitors. 
Such  ketones  are  proprione  (C5H10O)  >delded  by 


102         Fasting  and  Undernutkition  in 

proprionic  acid,  butyrone  (C7H14O)  from  butyric 
acid,  and  valerone  (CgHigO),  a  product  of  valeric 
acid.  The  close  chemical  relationship  of  the  suc- 
cessive members  of  the  fatty  acid  series  and  that 
of  their  respective  ketones,  and  the  facts  that 
they  are,  to  the  greater  part,  volatile  liquids 
which  are  readily  intermiscible  and  are  subject 
to  the  same  chemical  reactions,  give  strength  to 
the  assumption  that  one  member  of  the  series  of 
fatty  acids  or  ketones  may  preponderate  in  a 
given  case,  but  that  it  is  hardly  probable  that 
these  single  members  are  present  to  the  exclu- 
sion of  all  the  others.  Originating  in  the  organ- 
ism from  practically  the  same  source  or  sources 
and  being  affected  by  the  identical  chemical  in- 
fluences, it  is  obvious  why  more  than  one  of  the 
lower  fatty  acids  and  more  than  one  of  their 
ketones  are  apt  to  occur  at  a  time,  and  why  the 
phenomena  of  acidosis,  which  are  by  no  means 
invariable  and  uniform,  must  of  necessity  be  the 
result  of  the  conjoint  activity,  or  be  the  concomi- 
tants of  various  fatty  acids  and  various  ketones. 
It  is  probably  true  that  there  is  no  case  of  gen- 
eral acidosis  in  which  acetone  or  its  immediate 
forerunner,  diacetic  acid,  cannot  be  demonstrated 
in  the  urine ;  this,  however,  is  no  conclusive  proof 
that  other  ketones  or  their  corresponding  fatty 
acids  are  not  found  associated  with  the  former. 
It  is  simply  the  readiness  with  which  acetone  and 
diacetic  acid  are  detected  in  the  urine  that  has 
given  them  a  clinical  prominence  which,  in  reality, 


The  Treatment  of  Diabetes  103 

they  do  not  deserve.  Were  the  other  ketones 
and  fatty  acids  as  easy  of  demonstration,  the 
acetone  bodies  and  their  direct  progenitors  would 
not  almost  exdusively  be  held  responsible  for  the 
production  of  acidosis. 

While  the  occurrence  of  acetonuria  may,  there- 
fore, furnish  convincing  evidence  of  an  imminent 
or  already  established  acidosis,  it  is  in  itself  no 
proof  that  other  members  of  the  low  fatty  acid 
series  have  not  participated  in  establishing  this 
abnormal  state,  or  that  a  ketone  or  ketones  other 
than  acetone  stands  at  the  foundation  of  the 
anomaly. 

The  question  concerning  us,  however,  is  not 
that  of  acidosis  but  of  the  presence  or  production 
of  ketones  prior  to  absorption. 

Hilliger,^  and  with  him  the  modern  clinical 
school,  is  of  the  opinion  that  the  liver  is  the  place 
of  formation  of  the  acetone  bodies.  They  assume 
that  here  they  are  probably  generated  as  inter- 
mediary metabolic  products  which,  physiologi- 
cally, are  almost  entirely  oxidized  to  CO2  and 
HO2.  Borchardt  ^  had  eight  years  previously 
maintained  the  same  standpoint,  namely,  that  the 
acetone  bodies  are  intermediary  metabolic  sub- 
stances, resulting  when  carbohydrates,  glycosides 
and  glycerine  are  withheld  from  oxidation. 

There  is  little  doubt,  if  any,  that  the  bulk  of 
the  ketones  that  are  produced  after  the  stage  of 
absorption  are  due  to  a  certain  form  of  hepatic 
insufficiency.    That  some  of  the  ketones,,  however^ 


104        Fasting  and  Undernutrition  in 

may  reach  the  intestinal  tract  in  a  preformed  or 
nearly  preformed  state,  or  that  they  may  be 
yielded  and  elaborated  during  pancreatic  and  in- 
testinal digestion  will  be  evinced  in  the  following 
lines. 

Some  recent  writers,  particularly  Howland  and 
Marriott  ^  maintain  that  hyperpnea  virtually 
spells  acidosis.  This  is  undoubtedly  true.  When 
there  is  an  intestinal  ketone  formation  and  the 
liver  is  functionating  properly,  a  ketonemia  will 
either  not  ensue  at  all  or,  it  will  be  so  transitory 
and  insignificant  an  occurrence  that  a  hyperpnea 
will  not  be  produced.  In  other  words,  ketones 
in  the  intestinal  tract  may  give  rise  to  various 
intestinal  affections  without  concomitant  keto- 
nemia and  hyperpnea.  In  fact,  the  confinement 
of  ketones  within  the  intestines  is  in  almost  every 
instance  not  followed  by  any  evidence  of  intoxi- 
cation or,  for  that  matter,  may  not  even  result 
in  any  local  clinical  symptoms. 

However,  many  diarrheal  disorders,  preemi- 
nently in  childhood,  are  caused  by  the  irritating 
activity  of  ketones  upon  the  intestinal  mucosa. 
To  understand  the  untoward  local  influence  of 
most  of  the  ketones  I  wish  to  recall  the  abundant 
experimental  and  clinical  work  anent  the  fatty 
diarrheas,  so-called.  Accordingly,  in  intestinal 
ketone  formation  we  have  to  deal  with  a  vicious 
circle,  i.e.,  a  perverse  disintegration  of  fatty  sub- 
stances in  the  alimentary  tract  on  account  of  pan- 
creatic or  intestinal  insufficiency,  a  local  hyper- 


The  Treatment  of  Diabetes  105 

emia,  catarrh,  etc.,  and  a  continuous  irritation  of 
the  local  process  for  reason  of  the  continued  per- 
verse or  increased  elaboration  of  ketones  from 
the  volatile  fatty  acids.  This  vicious  circle  is 
only  broken  by  withholding  the  foodstuffs  that 
yield  measurable  quantities  of  ketones. 

A  fatty  diarrhea  is  to  all  intents  and  purposes 
a  ketone  diarrhea,  that  is  to  say,  it  is  not  pro- 
duced by  the  fatty  acids  of  low  molecular  weight 
but,  in  some  degree  at  least,  by  the  ketones  they 
have  yielded.  The  ketone  diarrhea,  like  the  fatty 
diarrhea,  may  ensue  without  any  systemic  symp- 
toms whatever.  If  it  continues  for  more  than 
thirty-six  hours  it  is  usually  accompanied  by  loss 
of  strength  and  body  weight.  In  case  it  prevails 
for  a  protracted  period,  either  in  a  continuous 
or  the  more  common  intermittent  form,  it  is  liable 
to  give  rise  to  marasmus  and  general  atrophy. 
Even  in  the  gravest  types  of  atrepsia  it  is  un- 
likely that  one  has  to  primarily  deal  with  an  in- 
toxication. Hyperpnea  never  supervenes  in  un- 
complicated cases  and  is  certainly  not  an  evi- 
dence of  enterogenously-f  ormed  ketones  that  have 
not  penetrated  the  intestinal  wall.  In  all  these 
cases  one  is  hardly  justified  in  speaking  either  of 
a  ketonemia  or  an  acidosis.  Ketonemia  or  acido- 
sis may  undoubtedly  concur  with  enterogenous 
ketones;  however,  the  clinical  picture  of  intes- 
tinal ketonosis  as  such  is  due  to  the  local  action 
of  the  enterogenous  ketones  contained  within  the 
bowel. 


106        Fasting  and  Undernutbition  in 

Ketones,  on  the  other  hand,  find  their  way  very 
readily  into  the  general  blood  stream.  This  is 
rather  the  normal  occurrence  when  the  liver  does 
not  sufficiently  functionate  to  cause  their  physio- 
logical cleavage  after  they  have  been  carried  to 
the  portal  circulation.  While  in  cases  of  acid 
intoxication  the  liver  is  the  organ  in  and  by  which 
the  acetone  bodies  are  produced  as  intermediary 
metabolic  substances,  and  are  not  physiologically 
split  up  into  simpler  bodies  in  intestinal  ketono- 
si.s,  when  the  ketones  enter  the  alimentary  tract 
either  in  a  preformed  state  or  are  elaborated 
therein,  the  normally  functioning  liver  is  the 
principal  line  of  defense  against  qualitatively  or 
quantitatively  abnormal  intestinal  substances. 

Symptoms 

The  symptoms  of  intestinal  ketonosis  are  in  a 
degree  negative  in  character,  but  positive  evi- 
dence is  not  missing. 

General  Appearance. — The  patient  usually 
looks  undernourished,  weak  and  anemic. 

Diarrhea, — ^Loose  or  watery  discharges  from 
the  bowels  are  the  rule.  The  reaction  of  the 
stools  is  always  acid.  These  possess  usually  a 
butyric- valeric  odor.  When  recently  passed,  acet- 
one may  be  contained  therein.  (Acetone  in  the 
stools  may  be  detected  in  the  following  manner: 
The  fresh  feces  are  first  well  diluted  with  water, 
acidified  with  acetic  acid,  and  then  distilled.  The 
distillate  (10  e.c.)  is  treated  with  a  solution  of 
iodin  in  ammonium  iodid;  this  results  in  the 


The  Treatment  of  Diabetes  107 

formation  of  iodoform  and  a  black  precipitate  of 
nitrogen  iodin.  The  latter  gradually  disappears 
on  standing,  thus  rendering  visible  the  iodoform. 
This  test  is  reliable,  as  it  excludes  disturbing 
factors  and  sources  of  error  like  alcohol  and 
aldehyde). 

The  stools  may  be  macroscopically  fatty,  but 
this  is  not  necessarily  the  case.  Mucus  is  of 
rather  frequent,  blood  of  infrequent,  occurrence. 
The  diarrheal  attacks  may  alternate  mth  more 
or  less  protracted  periods  of  constipation. 

Ketonemia  and  Ketonuria. — Absorption  of  ke- 
tones may  take  place,  but  ketonemia  and  keto- 
nuria, when  present  at  all,  are  most  always  of 
very  brief  duration. 

Hyperpnea. — The  amount  of  ketones  which 
may  be  present  in  the  blood  at  any  one  time  is 
never  sufficient  to  give  rise  to  a  hyperpneic  con- 
dition. 

Ketones  in  the  Alveolar  Air, — The  alveolar  air 
is  free,  or  almost  so,  from  ketones.  The  ketone 
odor  emanates  from  the  alimentary  tract  and 
not,  as  in  ketonemia,  from  the  lungs. 

Ketones  in  the  Intestinal  Gases. — Ketones  may 
be  expelled  with  the  flatus.  Their  presence  can 
be  demonstrated  clinically  by  the  sense  of  smell 
only.  Of  course,  they  are  admixed  with  the  other 
gases  of  fermentation  and  putrefaction.  Pro- 
prione,  butyrone,  valerone  and  acetone  are  likely 
to  occur  in  the  flatus  when  their  respective  pro- 
genitors are  found  in  the  feces. 


108         Fasting  and  Undernutrition  in 

Fever. — Temperature  elevation  may  or  may 
not  be  present.  It  may  occur  on  one  day,  but  may 
be  absent  on  the  next.  In  adults  the  eventual  in- 
crease hardly  ever  surpasses  two  deg.  F.  In 
children  below  four  or  five  years  of  age  the  rectal 
temperature  may  reach  104  to  105  deg.  F. 

Pain, — Abdominal  pain  is  not  always  present; 
it  is  hardly  ever  of  a  severe  type.  This  pertains 
to  children  as  well  as  to  adults.  A  pressure  point 
sensitiveness  is  often  found  about  the  cecal  re- 
gion. In  small  children  a  scorching  pain  about 
the  rectum  and  perineum  is  frequently  met  with. 
It  is  due  to  the  irritating  volatile  acids  and  their 
ketones  excreted  in  the  feces. 

The  Seat  of  Production  of  Intestinal  Ketonosis 

Normally  the  ketones  are  readily  absorbed 
on  account  of  their  great  volatility.  At  the  bot- 
tom of  intestinal  ketonosis  there  must  therefore 
stand  either  (1),  an  insufficiency  of  the  lacteal 
system  or  (2),  the  possibility  that  in  intestinal 
ketonosis  the  ketones  are  not  yielded  until  the 
residual  ingesta,  containing  the  lower  fatty  acids, 
have  reached  the  large  bowel.  A  number  of 
clinical  observations  have  convinced  me  that  a 
structurally  or  functionally  diseased  cecum,  hin- 
dering the  free  absorption  of  water,  is  the  fre- 
quent seat  of  the  formation  and  retention  of 
enterogenous  ketones.  A  few  of  the  pertaining 
observations  may  here  find  mention. 

Observation  I, — Patient  of  Dr.  Lack  of  Brook- 


The  Treatment  of  Diabetes  109 

lyn.  Married  ^voman,  twenty-seven  years  old,  one 
child.  Very  frail.  Undernourished  and  anemic. 
Penetrating  valero-hntyric  odor  from  mouth  when 
holding  breath.  The  odor  is  independent  from 
intake  of  food.  Feces  contain  acetone  as  well 
as  fatty  acids  and  soap  needles  for  a  long  period 
(two  months).  Occasional  ketonuria.  Chief 
complaints :  Extreme  prostration ;  diarrhea. 

Examination:  Nothing  was  found  of  patho- 
logical import,  except  cecal  regurgitation  and 
evidence  of  Jacksonian  bands. 

Treatment. — Operation  by  Dr.  Lack.  Kemoval 
of  appendix  and  Jacksonian  membranes;  ceco- 
pexy.  Complete  recovery  from  intestinal  ke- 
tonosis. 

Observation  II. — Married  woman,  thirty-eight 
years  old,  one  child.  Eather  thin,  anemic.  Ean- 
cid  odor  from  mouth  when  holding  breath.  Feces 
contain  valeric,  butyric,  aceto-acetic  acid,  acetone 
and  large  amounts  of  mucus.  No  ketonuria. 
Chief  complaints :  Eestlessness ;  pain  over  course 
of  transverse  colon;  diarrhea  alternating  with 
constipation;  dr^oiess  in  throat. 

Examination :  A  cecum  of  great  length  and  very 
movable  was  found. 

Treatment. — Operation  by  Dr.  Fischer.  Ee- 
moval  of  appendix.  Cecopexy.  Complete  recov- 
ery from  intestinal  ketonosis. 

Observation  III. — Man,  thirty-six  years  old. 
Present  weight  142  pounds,  but  has  lost  over 
thirty  pounds  in  five  months.    Aceto-valero-buty- 


110         Fasting  and  Undeenutrition  in 

ric  odor  from  mouth  when  holding  breath.  Odor 
is  practically  always  present.  No  acetonuria. 
Feces  contain  fatty  acids,  soap  needles  and  ace- 
tone. Chief  complaints:  Pain  and  soreness  in 
left  inguinal  region;  irritability;  attacks  of 
diarrhea. 

Examination:  By  colonoscope  no  sign  of  dis- 
ease of  rectum  and  sigmoid  discernible.  Gurg- 
ling sounds  in  the  cecum,  pointing  to  atony  of 
this  part  of  the  gut,  are  much  in  evidence. 

Treatment. — Operation  by  Dr.  Fischer.  Re- 
moval of  appendix.  Cecopexy.  Complete  recov- 
ery from  intestinal  ketonosis. 

I  could  recount  a  number  of  similar  cases  in 
which  an  intestinal  ketonosis  disappeared  after 
the  removal  of  the  appendix,  bands  and  adhesions 
about  the  cecal  region  and  with  or  without  ceco- 
pexy. In  other  cases,  especially  in  nurslings  and 
children,  operative  interference  is  not  indicated. 
In  these  cases  a  rational  change  of  diet  is  always 
followed  by  a  suppression  of  the  intestinal  ke- 
tonosis. 

Sources  of  Intestln<il  Ketonosis 

The  mother  substances  of  intestinal  ketones  are 
the  volatile  fatty  acids.  These  volatile  fatty  acids 
are  contained  in  milk  and  they  form  a  goodly 
percentage  of  the  fat  of  cow's  milk,  of  butter  and 
of  some  other  milk  products.  Volatile  fatty  acids 
are  also  yielded  as  cleavage  products  of  other 
fatty  substances,  of  proteids  and  carbohydrates; 


The  Treatment  of  Diabetes  111 

however,  the  amounts  thus  obtained  are  very 
small,  as  a  rule.  It  stands  to  reason  that  prac- 
tically all  the  volatile  fatty  acids  in  bottle-fed 
infants  are  yielded  by  the  milk-fats.*  In  nornial 
adults  on  a  mixed  diet  the  amount  of  volatile 
fatty  acids  is  rather  insignificant,  unless  there  be 
a  distinct  alimentary  disorder.  Wlien  put  on  a 
milk  regimen  or  when  an  adult  consumes  large 
amounts  of  butter  or  certain  cheeses,  the  volatile 
fatty  acids  will  increase  at  once. 

The  entire  secret,  then,  to  overcome  intestinal 
ketonosis  in  infants  as  well  as  in  adults,  consists 
in  the  withdrawal  of  the  milk-fats  and  the  sub- 
stitution therefor  of  fats  of  higher  melting  point. 

Ejifeeences 
iHilliger:    Jalirbuch   f.   Kinderheilkunde,    1914,   Vol.   LXXX, 

p.  1. 

2  Zentralblatt  f .  d.  gesamte  Physiologie  u.  Pathologie  d.  Stoff- 

wechsels,  1906,  Vol.  I. 

3  Jolins  Hopkins  Hospital  Bulletin,  March,  1916. 

Ill 

Concerning  the  Suppression  of  the  Acetone 
Bodies  in  Diabetics 

In  whatever  manner  the  substances  of  the  ace- 
tone group  arise,  they  are  a  symptom  of  inani- 
tion indicating  decline  of  the  diabetic  organism. 

*  Besides,  a  certain  proportion  of  the  fecal  acidity  is  un- 
doubtedly caused  by  the  intestinal  microorganisms  whose  number 
and  activity  are  often  pathologically  increased  in  many  of  the 
alimentary  disturbances  of  infantile  and  adult  life. 


112         Fasting  and  Undernutrition  in 

Acetonuria  in  the  diabetic  occurs  independently 
of  the  degree  of  the  glycosuria — that  is,  its  inten- 
sity is  not  reflected  by  a  corresponding  intensity 
of  the  latter.  On  the  other  hand,  the  degree  of 
acetonuria — when  all  circumstances  are  duly  con- 
sidered— may  afford  a  fair  insight  as  to  the  ex- 
tent of  tissue  waste.  Furthermore,  the  presence 
of  an  excess  of  the  acetone  bodies  may  point  to 
either  an  inability  of  certain  organs  to  convey  the 
introduced  alkalies  to  the  structures  in  need  of  it, 
or  else,  to  the  insufficient  diffusion  and  ionization 
of  the  salts  in  the  body  liquids. 

The  formation  of  the  acetone  bodies  will  not 
ensue  as  long  as  one  can  manage  that  the  diabetic 
remains  in  a  fair  state  of  nutrition ;  if  this  proves 
impossible  in  the  course  of  time — an  inevitable 
occurrence  supervening  sooner  or  later — the  gen- 
eral deterioration  should  be  retarded  by  all  pos- 
sible means.  The  waste  of  the  diabetic  organism, 
in  fact,  may  be  so  gradual,  that  urinary  acetone 
may  not  appear  in  excess  of  0.25  gram  in  the 
twenty-four  hours. 

If  acetonuria  and  diaceturia  occur  in  a  pro- 
nounced degree,  attempts  should  be  made,  repeat- 
edly if  necessary,  to  suppress  the  further  produc- 
tion of  the  acetone  bodies,  or,  if  these  fail,  to 
keep  their  formation  at  a  minimum.  By  adding 
carbohydrates  to  the  nourishment  the  acidosis 
may  decrease  for  the  time  being,  v.  Noorden* 
highly  recommends  his  '* Oatmeal  cure''  for  this 
purpose,  which  is  carried  out  in  the  following 


The  Treatment  of  Diabetes  113 

manner:  Patient  ingests  every  day  for  a  period 
of  from  one  to  two  weeks,  to  the  exclusion  of 
everything  else,  a  soup  composed  of  oatmeal  250 
grams,  butter  250  grams  to  300  grams,  and  some 
vegetable  albumin  100  grams.  A  portion  of  this 
soup  is  partaken  of,  every  two  hours. 

There  is  no  doubt  that  the  degree  of  acidosis 
is,  as  a  general  rule,  temporarily  reduced  when 
carbohydrates  are  admitted  to  the  diet.  How- 
ever, they  should  not  be  partaken  of  for  longer 
than  three  or,  at  the  utmost,  four  days,  as  other- 
wise the  inevitably  increased  glucose  output  will 
make  itself  felt  in  a  manner  not  to  be  misunder- 
stood. A  short  time  after  the  carbohydrates  are 
discontinued,  the  acetone  bodies  are  again  ex- 
creted in  similar  amounts  as  before  the  admit- 
tance of  the  starchy  matters  to  the  nourishment. 
Thus,  although  carbohydrates  may  alternately  be 
permitted  and  mthdrawn  for  some  weeks,  noth- 
ing has  been  gained  in  the  end.  It  is  true,  a  fatal 
issue  might  have  been  averted,  but  whether  this 
was  imminent  is  a  matter  of  mere  speculation. 
On  the  other  hand,  the  ingestion  of  carbohy- 
drates, irrespective  of  the  form  in  which  they  are 
taken,  whether  of  oatmeal,  or  of  potatoes,  as  sug- 
gested by  Mosse,^  or  of  milk,  may  occasion  vastly 
more  injurious  results  than  would  have  ensued 
had  they  not  been  added  to  the  food. 

Furthermore,  the  oatmeal  cure  is  not  only  dis- 
gusting to  the  patient,  but  it  does  not  uphold 
the  claims  of  its  author.    Oatmeal,  in  my  experi- 


114         Fasting  and  Undernutrition  in 

ence,  is  not  any  better  tolerated  by  the  diabetic 
exhibiting  acetonuria,  than  other  amyloid  sub- 
stances, as  buckwheat,  or  rice,  for  instance. 
Again,  the  very  large  amount  of  butter,  250 
grams  to  300  grams  daily,  which  is  to  be  incor- 
porated into  the  oatmeal  gruel,  contradicts  the 
rationale  of  acidosis  therapy.  Half  a  pound  of 
butter,  or  more,  ingested  daily,  is  certainly  apt 
to  yield  large  quantities  of  acetone  bodies  in  the 
diabetic;  as  a  matter  of  fact,  I  have  seen  a  case, 
after  restriction  to  the  oatmeal-fat-albumin  com- 
pound for  some  days,  in  which  the  intensity  of  the 
acetonuria  had  not  only  not  diminished,  but  had 
been  appreciably  augmented. 

In  his  oatmeal  cure,  v.  Noorden  (who  himself 
has  shown  that  the  ingestion  of  more  than  150 
grams  of  unwashed,  and  of  more  than  180  grams 
or  200  grams  of  washed  butter — ^by  the  washing 
process  butter  loses  its  low  fatty  acids — is  liable 
to  be  followed  by  an  increased  production  of  ace- 
tone bodies)  orders  the  addition  of  from  250 
grams  to  300  grams  of  butter.  Does  he  really 
think  that  the  250  grams  of  oatgruel  suppresses 
the  already  existing  acidosis  and  prevents  the 
yielding  of  acetone  bodies  by  the  over-supply  of 
butter? 

If  we  wish  to  cope  successfully  with  acidosis 
without  aggravating  the  diabetic  condition  we 
can  neither  add  starches  to  the  nourishment  for 
any  length  of  time  nor  can  we  in  most  cases  in- 


The  Treatment  of  Diabetes  115 

crease  the  amount  of  protein  substances.*  There- 
for, nothing  remains  but  to  turn  again  to  the 
fats,  that  is  to  such  fatty  ingesta,  which,  if  at  all, 
contain  but  small  amounts  of  fatty  acids  of  low 
molecular  weight.  According  to  the  investiga- 
tions of  Leo  Schwartz,^  the  fatty  acids  which  may 
be  considered  mother  substances  of  acetone  bodies 
are  valerianic,  butyric  and  caproic  acids;  fatty 
acids  of  high  molecular  weight,  like  palmitic, 
stearic  and  especially  oleic  acids,  yield  compara- 
tively little  acetone.  Hence,  butter  and  cream, 
are  productive  of  largely  increased  acidosis, 
while  lard,  suet  and  particularly  olive  oil  do  not 
cause  a  very  marked  augmentation  of  the  acetone 
bodies. 

The  clinician  who  is  attending  a  case  of  grave 
diabetes  complicated  by  pronounced  acidosis, 
finds  himself  in  a  dilemma.  Were  he  to  prescribe 
a  diet  consisting  of  nothing  else  but  small 
amounts  of  proteins  and  large  quantities  of  lard, 
suet  or  olive  oil,  the  patient  would  soon  be  tired 
of  this  regimen  and  his  nutrition  would  not  only 
be  not  improved  but  his  digestive  organs  might 
become  seriously  disordered.  Besides,  and  this 
should  not  be  forgotten,  the  vegetable  oils  are  as 
a  rule  not  well  tolerated  if  they  are  used  in  larger 
than  the  ordinary  amounts,  and  lard  (frequently 

*  The  albuminous  ingesta  in  grave  cases  of  diabetes  do  not 
only  augment  the  glucose  output  but  are  liable  to  putrefy  in 
the  alimentary  canal  whereby  butyric  and  valerianic  acids,  the 
precursors  of  the  acetone  bodies,  are  formed. 


116        Fasting  and  Undernutrition  in 

not  well  borne  in  even  moderate  quantities)  and 
beef  suet  can  neither  be  relied  upon  for  suppress- 
ing an  already  existing  acidosis  nor  to  improve 
the  nutrition  of  the  diabetic  organism. 

There  is  only  one  fatty  article  of  food  which  I 
found  well  adapted  to  the  needs  of  the  diabetic 
organism  during  acidosis — this  is  the  yolk  of  the 
hen's  egg,  I  have  very  rarely  seen  it  produce  or 
increase  the  acetone  substances,  or  call  forth  di- 
gestive or  assimilative  disturbances  in  advanced 
diabetes.*  Partaken  of  in  the  raw  or  semi-raw 
condition,  fresh  yolks  may  be  consumed  in  almost 
any  quantity  without  calling  forth  satiation  or 
fulness. 

The  rationale  of  the  ''yolk  cure,"  which  will 
be  described  in  detail,  I  attribute,  among  others 
to  the  following  four  main  factors: 

1,  Palmitin,  stearin,  and  olein,  the  fat  sub- 
stances of  the  yolk,  occasion  but  small  amounts 
of  acetone  bodies;  in  combination  in  which  these 
fats  exist  in  the  yolk,  they  yield  no  butyric  acid, 
or  hardly  any. 

2.  The  large  amount  of  lecithin,  supplied  to 
the  organism  by  the  yolk,  tends  to  the  restoration 
of  nerve  force  and  the  amelioration  of  the  cachec- 
tic condition. 

*  The  "idiosyncrasy"  for  eggg  not  infrequently  met  in  even 
healthy  persons  seems  to  be  evoked  in  the  first  instance  by  the 
white  of  the  egg.  None  of  the  diabetics  whom  I  had  under  my 
"yolk  cure,"  nor  a  number  of  other  undernourished  persons  in 
whose  diet  yolks  preponderated,  developed  an  idiosyncrasy  for 
the  latter. 


The  Treatment  of  Diabetes  117 

3.  The  occurrence  in  the  yolk  of  a  diastatic 
ferment  assisting  in  the  conversion  of  amyloid 
substances  introduced  by  proteids  and  allowed 
vegetables. 

4.  The  properties  of  the  yolk  to  stimulate  the 
digestive  secretions. 

The  first  and  second  factors  are  too  well  under- 
stood to  be  again  exploited  on  this  occasion.  Con- 
cerning the  third,  Mueller  and  Masuyama"^  found 
in  the  hen's  egg,  more  particularly  in  the  yolk, 
a  diastatic  ferment  which  has  the  ability  of 
forming  erythrodextrin,  then  achroodextrin,  and 
finally  isomaltose.  The  converting  power  of  the 
ferment  is  less  pronounced  and  less  acute  than 
that  of  the  salivary  and  pancreatic  ferment,  but 
it  can  diastatize  as  much  as  forty-five  per  cent, 
of  the  food  during  the  day. 

As  regards  the  fourth  factor,  I  msh  to  state 
that  Ssoborow,  a  pupil  of  Pawlow,  some  years 
ago  demonstrated  the  marked  stimulating  in- 
fluence of  the  yolk  of  the  hen's  egg  upon  the  gas- 
tric glands ;  he  found  that  the  amount  of  gastric 
juice,  obtained  after  feeding  yolks  to  dogs  whose 
stomachs  had  been  isolated,  was  greater  than 
after  ingestion  of  any  other  articles  of  food. 
Obesersky,^  confirming  these  observations  from 
the  clinical  standpoint,  concludes  that  the  yolk  of 
the  hen's  egg  exerts  a  pronounced  influence  upon 
the  hydrochloric  acid  glands  of  the  gastric  mucosa 
and  that  the  yolk  not  only  stimulates  the  stomach 
to  greatly  increased  secretory  activity,  but  that 


118         Fasting  and  Undernutrition  in 

its  frequent  ingestion  activates  the  acid  glands 
to  such  a  degree  that  yolks  may  be  employed  as 
digestants  in  affections  characterized  by  lack  of 
hydrochloric  acid.  My  own  observations  upon 
the  stimulating  influence  of  yolks  on  the  digestive 
secretions  substantiate  the  contentions  of  the 
Eussian  investigators. 

The  *^yolk  cure"  consists  in  the  ingestion  of 
from  ten  to  forty  yolks  a  day,  together  with  a 
small  amount  of  proteids  and  the  non-avoidable 
carbohydrates  furnished  by  the  latter  and  certain 
allowed  quantities  of  green  vegetables.  As  each 
yolk  contains  about  5  grams  of  fat  representing 
more  than  46  calories,  it  takes  about  21  yolks  to 
furnish  1,000  and  about  32  yolks  to  make  up  1,500 
calories.  A  diabetic  weighing  60  kilograms,  in- 
gesting 21  yolks  a  day,  would,  therefore,  obtain 
in  fat  alone  16.6  calories  per  day  and  kilogram  of 
body- weight;  taking  32  yolks  a  day  the  average 
for  each  kilogram  of  his  absolute  weight  would 
be  25  calories.  Yolks  sufficient  to  yield  from  10 
to  15  calories  per  day  and  kilogram  of  body- 
weight,  however,  are  all  that  are  necessary  to  be 
ingested  in  grave  cases  of  diabetes  complicated 
by  acidosis. 

The  ^^yolk  cure,"  besides  suppressing  the  ace- 
tone bodies,  causes  systemic  and  nutritive  im- 
provement, and  increase  of  body-weight,  vigor, 
and  resistance.  It  also  stimulates  body-growth 
in  the  diabetic  child  or  adolescent. 

The    **yolk    cure"    supplies    but    very    small 


The  Treatment  of  Diabetes  11.9 

amounts  of  nitrogen.  However,  it  is  body-albu- 
min sparing  in  a  much  higher  degree  than  any 
other  dietary  regimen.  Of  course,  the  excreted 
nitrogen,  wliile  the  patient  is  under  the  strict 
**yolk  cure,''  exceeds  that  which  has  been  in- 
gested; the  deficit,  however,  is  so  trifling  that, 
practically,  it  does  not  need  to  be  taken  into  ac- 
count. This  is  especially  the  case  when  the  yolk 
days  alternate  with  protein-fat  (yolk)  days. 
Again,  when  the  glycosuria  is  moderate,  so  that 
larger  quantities  of  albumin,  together  with  yolks, 
instead  of  suet  or  butter,  may  be  partaken  of,  a 
nitrogen  deficit  may  be  averted  altogether. 

The  teclmic  of  the  ^'yolk  cure''  is  quite  simple. 
The  diet  on  which  the  patient  had  been,  is  at  once 
discontinued;  this  is  best  done  by  omitting  the 
next  meal.  In  the  meantime  the  patient's  intes- 
tinal tract  is  evacuated,  after  which  a  high  saline 
enema  should  be  administered.  When  the  de- 
cline of  the  patient  has  been  very  rapid,  and  when 
the  glycosuria  and  acetonuria  are  of  a  high  de- 
gree of  intensity,  the  exclusive  ^^yolk  cure"  must 
be  continued  until  general  improvement  has  en- 
sued. In  other,  less  pronounced  cases,  it  may 
suffice  to  have  a  *'yolk  day"  twice  or  three  times 
a  week,  while  the  regular  protein- fat  (yolk)  regi- 
men is  pursued  on  the  other  days.  In  a  small 
percentage  of  the  cases  larger  amounts  of  car- 
bohydrates may  be  permitted  when  the  improve- 
ment has  continued  for  some  time.  The  addi- 
tional carbohydrates  should  be  given  in  the  form 


120 


Fasting  and  Undernutrition  in 


of  green  vegetables,  and  not  in  that  of  flour, 
beans,  rice,  or  potatoes.  In  whatever  manner  the 
yolk  diet  is  altered,  the  yolks  should  continue  to 
displace  all  other  kinds  of  fat,  and  a  strict  yolk 
day  should  be  pursued  at  least  once  or  twice  a 
week  for  a  protracted  period. 

A  sample  of  a  yolk  menu  is  given  in  the  fol- 
lowing table : 


Breakfast : 

Cup  of  coffee,  with  two  yolks 

Three  boiled  yolks 

Early  lunch : 

Egg-nog  (three  yolks^  30  cc.  whiskey).. 

Dinner : 

Celery  soup  (five  yolks) 

Spinach,  250  grams,  eight  yolks 

Cup  of  coffee,  with  two  yolks 

J,PM, 

180  cc.  sugar-free  red  wine,  one  yolk — 

Supper : 

One  plate  soup  (soup  stock),  five  yolks. . 
String  beans,  90  grams,  three  yolks 

Total 


m 

o 

2  ^ 

2  ."53 

1 

2 

92 

92 

3 

138 

138 

3 

138 

270 

5 

230 

230 

8 

368 

443 

2 

92 

92 

1 

46 

125 

5 

230 

250 

3 

138 

150 

32 

1,472 

1,790 

(The  administration  of  alkalies,  although  the 
influence  of  the  latter  upon  diabetic  acidosis,  as 
pointed  out  by  me^  seems  to  be  a  mere  local  and 
limited  one,  is  an  innocent  procedure,  and  may 
be  pursued  as  an  adjuvant  to  the  antiacetone  diet. 
It  is  possible  that  alkalitherapy  for  a  time  averts 


The  Treatment  of  Diabetes  121 

the  enterogenous  production  of  acetone  sub- 
stances, but  it  is  a  mooted  question  whether  alka- 
lies alone,  that  is,  when  the  diet  under  which  ace- 
tone has  been  formed  is  continued,  will  bring 
about  cessation  of  an  already  active  acetone  pro- 
duction.) 

In  order  to  avoid  monotony,  variety  in  soups, 
vegetables,  flavoring,  and  seasoning  substances 
should  be  planned.  The  following  cooking  recipes 
for  yolk  dishes  will  be  found  of  service : 

PLAIN   YOLKS 

Boil,  shirr  or  poach  the  whole  egg — only  the 
yolks  should  be  consumed. 

coffee 

stir  the  yolks  of  two  eggs  in  a  cup,  then  add 
one  cup  of  hot  coffee  stirring  constantly. 

wine  soup 

Let  150  c.c.  of  red  (sugar-free)  wine  and  the 
same  amount  of  water,  a  little  cinnamon  and  one 
clove  come  to  a  boil.  Eemove  from  the  fire  and 
stir  in  the  yolks  of  two  or  three  eggs  stirring  con- 
stantly.   Add  saccharin,  if  desired. 

SPINACH   AND   ALL  GREEN   VEGETABLES 

Boil  in  salted  water  until  very  tender — drain — 
add  pepper  and  mash  to  pulp  or  press  through 
colander.  Then  add  to  each  ounce  of  pulp  one 
raw  yolk  and  mix  w^ell. 


122         Fasting  and  IJNDERNUTRiTioisf  IIT 

SALAD    DKESSING 

Mix  the  yolks  of  six  eggs  (well  beaten)  with 
salt,  pepper,  one  teaspoonM  of  onion  juice  and 
mustard.    And  juice  of  half  a  lemon. 

CELERY   AND    CAULIFLOWER    SOUP 

Boil  a  stalk  of  celery  (cut  fine)  in  250  c.c.  of 
salted  water  until  very  tender — strain  and  add  to 
the  boiling  liquid  the  well-beaten  yolks  of  five 
eggs.    Season  to  taste. 

Cauliflower  which  has  been  scalded  is  put  on 
to  boil  with  250  c.c.  of  salted  water,  when  very 
tender  the  whole  mixture  is  passed  through  a 
colander  and  returned  to  the  fire,  then  the  well- 
beaten  yolks  of  five  eggs  are  added.  Season  to 
taste. 

SOUP    STOCK 

For  each  plate  of  soup  a  quarter  pound  of  shin 
meat,  a  quarter  pound  bone,  some  celery,  parsley, 
one  onion  and  half  of  a  leek  are  required.  Set 
on  the  fire  with  cold  water  and  boil  slowly  for 
five  hours.  Strain,  pressing  meat  to  a  pulp  so  as 
to  extract  all  the  juice.  Then  add  five  yolks,  well 
beaten. 

EGG-NOG 

Mix  30  c.c.  whiskey  with  90  c.c.  water  and  shake 
or  stir  briskly  with  the  yolks  of  two  eggs — add 
nutmeg,  cinnamon,  or  lemon. 

All  yolk  dishes  must  contain  salt  in  sufficient 


The  Treatment  of  Diabetes  123 

amount;  salt  not  only  aids  in  the  assimilation  of 
the  yolk  constituents,  but  is  absolutely  essential 
for  the  proper  conduct  of  the  metabolic  and  os- 
motic processes.  The  patient,  as  a  rule,  takes 
readily  to  the  yolk  cure.  I  have  some  patients 
who,  although  not  eliminating  acetone  bodies  any 
longer,  continue  of  their  own  volition  two  or 
three  yolk  days  in  the  week,  and  substitute,  as 
much  as  possible,  yolks  for  other  fatty  ingesta  on 
the  protein-fat  days. 

Generally,  obstipation  does  not  supervene 
while  the  patient  subsists  on  the  *^yolk  cure." 
However,  if  it  ensues,  high  enemas,  to  be  followed 
by  some  saline  cathartic  or  a  good  dose  of  castor 
oil,  to  be  followed  by  enteroclysis  with  sodiimi 
chlorid  solution,  should  be  at  once  administered. 

Following  are  the  histories  of  some  cases  of 
diabetes,  complicated  by  acetonuria  and  diace- 
turia,  which  had  been  under  the  strict  and  modi- 
fied yolk  diet : 

Case  I. — J.  E.,  forty-five  years  old,  is  a  diabetic 
since  his  thirty-ninth  year.  Between  March  and 
May,  1903,  his  affection,  which  had  been  of  a  com- 
paratively mild  type  for  five  years,  began  to  as- 
sume a  grave  character.  On  February  22,  1903, 
while  under  the  diet  which  he  pursued  for  the 
past  three  years,  and  which  contained  150  grams 
of  carbohydrates  per  day,  he  weighed  147% 
pounds,  and  his  urine  exhibited  neither  glucose, 
acetone  nor  diacetic  acid.  On  May  10,  his  weight 
had  declined  to  146%  pounds,  and  his  urine  (the 


124         Fasting  and  Undernutrition  in 

amount  of  which,  had  not  been  ascertained)  con- 
tained 1.5  per  cent,  glucose,  but  the  tests  for  ace- 
tone and  diacetic  acid  showed  neither.  On  May 
25,  while  under  a  rigid  meat-fat  regime,  he  ex- 
creted 4  per  cent.,  or  90  grams  of  glucose,  but  no 
acetone  or  diacetic  acid.  On  June  8  the  diurnal 
amount  of  excreted  glucose  had  diminished  some- 
what, but  there  were  traces  of  acetone,  and  the 
ferric  chlorid  reaction  was  fairly  pronounced. 
His  weight  was  1451/4  pounds.  About  June  25, 
he  consulted  Prof.  v.  Noorden,  at  Frankfort,  who 
informed  me  that  he  had  found  2.3  per  cent,  or 
56  grams  glucose,  and  1.5  grams  acetone  in  the 
twenty-four  hours'  urine,  and  that  the  ferric 
chlorid  reaction,  although  faint,  had  occurred. 

Upon  his  return,  on  September  13,  he  weighed 
144  pounds ;  his  urine  contained  large  amounts  of 
glucose  and  some  acetone,  but  no  diacetic  acid. 
On  September  23,  he  exerted  181.6  grams  glu- 
cose, a  small  amount  of  acetone,  but  no  diacetic 
acid.  On  September  25,  after  two  days  of  a  green 
vegetable  and  fat  (butter)  diet,  as  advised  by 
V.  Noorden,  he  excreted  but  83.4  grams  glucose, 
but  over  2  grams  acetone,  and  also  some  diacetic 
acid.  On  September  29,  his  weight  had  declined 
to  143%  pounds,  the  glucose  output  to  54.97 
grams,  the  amount  of  acetone  had  not  materially 
changed,  the  ferric  chlorid  reaction  was  positive. 
Keeping  the  patient  upon  a  very  rigid  diet  (com- 
plete exclusion  of  carbohydrates,  diminished 
amount  of  albumin,  no  egg  albumin,  only  the 


The  Treatment  of  Diabetes  125 

yolks),  he  weighed  14514  pounds  on  October  5, 
and  had  excreted  during  the  previous  24  hours 
about  43  grams  glucose,  and  traces  of  acetone; 
diacetic  acid  was  not  detected.  Withdrawing  all 
fatty  substances  except  the  yolks  of  eggs,  he 
weighed,  on  October  12,  148%  pounds.  The  glu- 
cose output  had  diminished  to  38.18  grams;  ace- 
tone had  entirely  disappeared.  Diacetic  acid  was 
not  present. 

Olive  oil,  added  to  the  diet  at  a  later  day,  was 
followed  by  a  slight  output  of  acetone;  addition 
of  butter,  tried  on  various  occasions,  caused  pro- 
nounced acetonuria.  Beef  fat,  in  the  amounts 
ordinarily  employed,  remained  mthout  influence 
upon  the  acetone  excretion.  The  patient  weighed 
1521^  pounds  on  November  30,  and  passed  as 
little  as  10  grams  glucose  on  January  10,  1904. 
His  urine  remained  entirely  free  from  acetone 
until  the  end  of  February.  Since  this  time,  small 
amounts  of  acetone,  as  well  as  of  diacetic  acid, 
are  found  occasionally.  His  present  weight  is 
149%  pounds.  Since  the  middle  of  October,  1903, 
his  diet  consists  of  meat  and  fish  and  their  natu- 
ral fat  substances,  of  gelatin,  green  vegetables, 
almond  cake,  coffee,  and  some  brandy.  The  daily 
caloric  deficit  is  made  up  by  the  yolks  of  hen's 
eggs,  of  which  he  had  as  many  as  14  per  day. 
These  are  incorporated  into  gravies  and  vege- 
tables, and  added  to  the  coffee  and  brandy. 

Case  U. — Mrs.  J.  D.,  forty-four  years  old,  who 
gave  birth  four  times,  three  times  to  stillborn 


126         Fasting  and  Undernutrition  in 

children,  consulted  me  first  on  April  16,  1903. 
The  patient  has  been  affected  with  diabetes  for 
abont  two  years,  and  had  exhibited  all  the  initia- 
tory symptoms  of  the  diabetic  state.  She  has 
lost  about  20  pounds  in  body-w^eight.  Her  pres- 
ent weight  amounts  to  IO314  pounds.  The  quan- 
tity of  urine  voided  in  the  twenty-four  hours  was 
2,800  c.c.  It  possessed  the  following  features: 
Specific  gravity,  1,033;  reaction,  0.45  deg.  acid; 
glucose,  8.35  per  cent.=233.8  grams  in  24  hours, 
acetone,  2.25  grams;  ferric  chlorid  reaction  very 
pronounced.  Albumin  and  evidence  of  renal 
lesion  could  not  be  detected.  Patient  was  put  on 
the  rigid  yolk  cure  for  three  days,  after  which  the 
yolk  days  were  to  alternate  with  protein-fat 
(yolk)  days  for  about  two  weeks,  after  this  two 
yolk  days  a  week  for  a  protracted  period.  On 
May  7,  the  diurnal  urine  amounted  to  not  quite 
2,000  c.c,  and  the  glucose  output  to  71  grams. 
The  excretion  of  acetone  bodies  had  ceased.  Pa- 
tient felt  strong,  and  weighed  104%  pounds.  On 
May  21,  the  twenty-four  hours  ^  urine  amounted 
to  1,850  c.c.  and  the  glucose  to  67.155  grams.  The 
acetone  substances  had  not  reappeared. 

Case  III. — M.  F.,  forty  years  old,  born  in 
Eussia,  butcher.  Symptoms  of  diabetes  first  no- 
ticed in  December,  1902.  Highest  weight,  155 
pounds.  Weight  on  May  2,  1903,  123^2  pounds. 
Urine  on  the  latter  day  amounted  to  5,400  c.c. 
and  contained  336.96  grams  glucose  and  large 
quantities  of  acetone  and  diacetic  acid.      Eigid 


The  Treatment  of  Diabetes  127 

protein-fat  (butter)  diet  reduced  the  diurnal 
urine  to  3,200  c.c,  and  the  glucose  to  85.12  grams 
after  two  weeks.  The  reactions  for  acetone  and 
diacetic  acid  had  become  more  intense.  Patient 
was  put  on  the  rigid  ^^yolk  cure"  for  two  days, 
and  on  alternating  yolk  days  and  protein-yolk 
days  for  two  weeks  longer,  with  the  result  that 
the  daily  glucose  output  had  diminished  to  less 
than  25  grams  and  that  the  acetone  substances 
had  entirely  vanished. 

Case  IV. — W,  S.,  tw^enty-five  years  old,  mer- 
chant, first  consulted  me  on  June  4,  1904.  The 
diabetic  phenomena  were  recognized  about  tw^o 
and  a  half  years  ago.  His  highest  weight  had 
been  155  pounds;  present  weight  109  pounds. 
Patient  is  also  affected  with  advanced  pulmonary 
tuberculosis.  The  saliva  contains  considerable 
amounts  of  glucose.  Urine,  quantity  voided  at 
my  office  at  one  time  900  c.c,  specific  gravity 
1,021,  glucose  5  per  cent.,  acetone  considerable, 
diacetic  acid  ferric  chlorid  reaction  positive.  No 
evidence  of  kidney  affection. 

Antidiabetic  regimen,  in  addition  thereto  about 
500  c.c.  of  sweet  cream  daily.  On  June  11  the 
glucose  had  been  reduced  to  2.4  per  cent.;  ace- 
tone and  diacetic  acid  occurred  in  rather  larger 
quantities.  On  June  19  patient  who  had  not  ad- 
hered  to  the  prescribed  diet  excreted  again  5  per 
cent,  glucose,  but  somewhat  less  acetone  and  dia- 
cetic acid.  His  weight  had  been  reduced  to  IO71/2 
pounds.    Protein-yolk  diet  and  every  third  day 


128         Fasting  and  Undernutrition  in 

a  vegetable-yolk  regimen  were  ordered.  June  25 
the  patient  feels  improved.  Urine  on  last  vege- 
table day  about  3,000  c.c. ;  on  last  protein-day 
4,000  c.c.  Glucose,  vegetable  day,  3.12  per  cent.; 
protein  day,  5.55  per  cent.  Specific  gravity,  vege- 
table day,  1,020.5;  protein  day,  1,021.5  Acetone, 
vegetable  day,  none;  protein  day,  traces.  Ferric 
chlorid  reaction,  vegetable  day,  negative;  pro- 
tein day,  faint. 

Case  V. — Mrs.  B.  C,  seventy- two  years  old, 
mother  of  9  children.  The  patient  was  first  seen 
by  me  on  June  18, 1904.  Diabetic  condition  dates 
back  for  some  years.  In  addition  thereto  she  has 
all  the  evidences  of  contracted  kidney.  Her  high- 
est weight  was  140  pounds;  present  weight 
amounts  to  108%  pounds.  Twenty-four  hours' 
urine,  2,000  c.c;  contains  large  quantities  of  al- 
bumin and  renal  debris,  0.83  per  cent,  glucose; 
acetone,  and  diacetic  acid  present.  Vegetable 
yolk-milk  diet  (from  12  to  22  yolks  a  day)  was 
ordered,  with  the  result  that  on  June  25,  glucose, 
acetone,  and  diacetic  acid  had  completely  disap- 
peared, and  the  amount  of  serum  albumin  was 
materially  reduced.  After  addition  of  100  grams 
of  bread  to  the  diet  she  was  still  free  from  glu- 
cose, acetone,  and  diacetic  acid  on  September  1, 
when  she  weighed  110  pounds.  She  still  subsists 
on  the  same  diet,  taking  little  meat,  but  about  12 
or  15  yolks  a  day.  The  amount  of  serum  albumin 
eliminated  by  the  urine  has  been  considerably 
reduced  since  treatment  was  started. 


The  Treatment  of  Diabetes  129 

Case  VL — G.  H.,  fifteen  and  one-half  years  old, 
was  referred  to  me  on  March  29,  1904.  Eight 
months  before  he  began  to  waste  away.  About 
three  months  before  the  family  physician  recog- 
nized diabetes.  The  diurnal  urine  amounted  to 
6,772  e.c. ;  the  specific  gravity  was  1,032.5 ;  glucose 
5.5  per  cent.,  that  is,  372.46  grams ;  it  also  exhibit- 
ed large  amounts  of  acetone  and  diacetic  acid.  He 
weighed  99  pounds.  A  moderately  rigid  diet  with 
100  grams  wheaten  toast  was  prescribed.  On  April 
9  the  twenty-four  hours'  urine  amounted  to  3,500 
c.c. ;  specific  gravity,  1,029;  glucose,  10  per  cent. 
(350  grams).  Acetone  and  diacetic  acid  contin- 
ued to  be  excreted  in  undiminished  quantities. 
The  patient's  weight  had  declined  to  98i/^  pounds. 
Kigid  proteid-fat  (butter)  diet  was  ordered.  On 
April  15  the  diurnal  urine  amounted  to  3,000  c.c. ; 
specific  gravity,  1,024;  glucose,  7.5  per  cent.  (225 
grams).  The  amount  of  acetone  and  diacetic  acid 
ivas  enormously  increased,  A  proteid-yolk  diet, 
and  twice  a  week  a  vegetable-yolk  day,  were  or- 
dered (23  yolks  on  the  latter  days). 

On  April  29,  the  urine,  vegetable  day,  amounted 
to  1,750  c.c;  on  the  previous  protein  day  it  had 
amounted  to  2,500  c.c.  The  urine  from  the  vege- 
table day  exhibited  2.5  per  cent.,  that  from  the 
proteid  day,  3.33  per  cent,  glucose.  Acetone  and 
diacetic  acid,  although  eliminated  in  decidedly 
smaller  quantities,  still  occurred  to  the  amount 
of  1.75  grams  on  the  last  vegetable  day,  and  to 
that  of  2.25  grams  on  the  last  proteid  day.    The 


130         Fasting  and  Undernutrition  in 

patient's  weiglit  had  risen  to  107  pounds.     The 
**yolk  cure''  was  ordered  to  be  continued. 

On  May  12,  a  vegetable  day,  the  urine  amounted 
to  1,500  c.c. ;  on  the  previous  protein  day  its 
amount  Avas  2,250  c.c.  The  urine  of  the  vegetable 
day  had  a  specific  gravity  of  1,020.5,  contained 
2.5  per  cent,  glucose,  gave  a  faint  ferric  chlorid 
reaction,  but  did  not  exhibit  acetone  in  more  than 
the  normal  amounts. 

The  urine  of  the  protein  day  possessed  a  den- 
sity of  1,027.5,  and  contained  6.25  per  cent,  glu- 
cose. Acetone  was  present  in  considerable  quan- 
tities and  the  ferric  chlorid  reaction  was  very 
pronounced.    The.  patient  weighed  111  pounds. 

On  May  26  the  urine  (vegetable  day — 28  yolks) 
amounted  to  1,750  c.c;  had  a  specific  gravity  of 
1,016,  and  contained  neither  glucose,  acetone,  nor 
diacetic  acid. 

The  urine  of  the  last  protein  yolk  day  (7  days) 
was  the  same  in  amount,  had  a  specific  gravity 
of  1,018,  and  contained  0.25  per  cent,  glucose  hut 
no  acetone  or  diacetic  acid.  The  weight  had  in- 
creased to  113  pounds.  Diet  continued  as  here- 
tofore. 

On  June  13,  a  vegetable  day  on  which  23  yolks 
were  consumed,  the  urine  amounted  to  1,250  c.c. 
It  had  a  specific  gravity  of  1,012,  a  general  acidity 
of  0.3  deg.,  and  contained  neither  glucose,  ace- 
tone, nor  diacetic  acid. 

The  urine  of  the  last  protein  day  amounted  to 
2,600  c.c,  had  a  specific  gravity  of  1,017,  a  general 


The  Treatment  of  Diabetes  131 

acidity  of  0.3  deg.,  and  contained  neither  glucose, 
acetone,  nor  diacetic  acid.  The  body-weight  had 
been  raised  to  116%  pounds.  On  the  last  few 
vegetable  days  patient  consumed  only  parsley 
which  had  been  cooked  in  ham  or  beef  water. 
The  yolks  were  incorporated  with  the  parsley. 
Treatment  continued  as  heretofore. 

On  July  6,  a  protein  day,  urine  was  excreted  to 
the  amount  of  4,250  c.c.  It  exhibited  a  specific 
gravity  of  1,019,  but  no  glucose,  acetone,  nor 
diacetic  acid. 

The  urine  of  the  last  vegetable-yolk  day 
amounted  to  2,125  c.c,  w^ith  a  specific  gravity  of 
1,014.  It  contained  no  glucose,  acetone  nor  dia- 
cetic acid.  The  weight  had  declined  to  115 
pounds.    Treatment  as  heretofore. 

On  July  27,  a  vegetable-yolk  day,  on  which  pa- 
tient had  consumed  30  yolks,  the  renal  secretion 
amounted  to  2,000  c.c,  had  a  specific  gravity  of 
1,015.75,  and  contained  no  abnormal  substance  of 
any  kind. 

The  urine  of  the  last  protein-yolk  day  amounted 
to  2,900  c.c,  had  a  specific  gravity  of  1,019.25,  and 
showed  neither  glucose,  nor  any  of  the  acetone 
bodies.  The  body- weight  had  declined  to  113^ 
pounds. 

On  August  17,  a  vegetable-yolk  day  (17  yolks), 
patient  voided  1,100  c.c.  urine,  the  density  of 
which  was  1,010.75.  It  exhibited  no  anomalous 
constituents. 

On  the  last  proteid  day  the  urine  amounted  to 


132         Fasting  and  Undernutrition  in 

2,600  C.C.,  possessed  a  specific  gravity  of  1,020.5, 
and  contained  no  abnormal  substances,  nor  nor- 
mal constituents  in  excess.  The  discrepancy  in 
discharged  solids  is  very  pronounced,  viz.,  22 
grams  on  the  vegetable  day,  116.5  grams  on  the 
protein  day.  Patient  yawns  incessantly,  and 
weighs  116%  pounds. 

On  September  14,  a  vegetable  day,  the  urine 
amounted  to  1,500  c.c,  and  had  a  density  of  1,018 ; 
it  contained  no  abnormal  substances. 

The  urine  of  the  last  protein-yolk  day  amounted 
to  2,500  c.c.  It  exhibited  a  specific  gravity  of 
1,019,  but  no  glucose  or  acetone  bodies.  The  pa- 
tient is  growing  fast,  feels  very  well  and  strong 
and  consumes  from  20  to  25  yolks  on  the  vege- 
table days  and  from  9  to  12  yolks  on  the  proteid 
days.    His  weight  was  118  pounds. 

On  October  15,  a  protein  day,  the  urine  was  ex- 
creted to  the  amount  of  2,250  c.c. ;  its  density  was 
1,021.  No  glucose  or  any  of  the  acetone  sub- 
stances were  contained  in  it. 

The  amount  of  the  urine  of  the  last  vegetable- 
yolk  day  was  1,500  c.c;  its  specific  gravity 
1,020.75.  No  abnormal  substances  were  detected 
in  it. 

The  patient  feels  very  well  and  has  been  work- 
ing in  a  factory  for  the  last  two  weeks.  He  con- 
sumes from  5  to  9  yolks  on  the  protein  days,  and 
from  22  to  30  yolks  on  the  vegetable  days.  He 
continued  to  grow.  His  weight  was  122i^,  and 
later  on  126%  pounds. 


The  Treatment  of  Diabetes  133 

A  study  of  the  cases  dwelled  upon  in  the  fore- 
going evinces  the  indisputable  value  of  the  **yolk 
cure''  in  ameliorating  the  diabetic  condition  and 
in  suppressing  the  production  of  the  acetone  sub- 
stances. While  I  do  not  believe  in  dogmatic 
dietary  rules,  I  maintain  that  the  principles 
underlying  the  ''yolk  cure''  are  rational  in  com- 
bating diabetes  complicated  with  excessive  pro- 
duction of  the  acetone  bodies. 

Refeeences 

*Von  Noorden:  Berliner  klin.  Wochenschr.,  1903. 

sMosse:    Memoires   communiques   k   I'Academie  de  m^decine, 

1901,  1902. 
eSchwarz:  Deutsches  Arch.  f.  klin.  Med.,  Bd.  76,  1903. 
TlSIueller  and  Masuyama:  Zeitschr.  f.  Biologie,  Bdr  39. 
sObesersky,  Medizina,  Nos.  47  and  48,  1899. 
astern:   Autointoxication  and  Its  Treatment,  1904. 


IV 

The  ''Yolk  Cure''  m  the  Treatment  of  the 

Underfed 

Who  is  underfed!— Some  time  ago  I  attempted 
to  answer  this  question.^^  I  concluded  that  under- 
weight and  underfed  are  not  synonymous  con- 
ceptions, that  an  individual  of  underweight  but 
in  metabolic  equilibrium  is  not  underfed,  and  that 
in  the  real  underfed  there  is  always  a  traceable 
disease  or  disorder  which,  directly  or  mediately, 
prevents  normal  ingestion  or  complete  utilization 


134         Fasting  and  Undernutrition  in 

of  foodstuffs,  giving  rise  thereby  to  bodily  de- 
cline. 

Does  overfeeding  alone  avert  the  further  de- 
terioration or  does  it  tend  to  restore  lost  body- 
substance  in  these  instances'?  No, — overfeeding, 
on  the  contrary,  may  even  call  forth  aggrava- 
tion of  the  patient's  condition  on  account  of  over- 
loading, overburdening  the  digestive  organs  and 
overproduction  of  alimentary  poisons. 

As  overfeeding  per  se  is  not  a  rational  thera- 
peutic procedure,  what  ought  we  to  do  to  prevent 
further  waste  and  to  cause  reparation  of  lost 
body-substance?  We  must  attempt  to  prepare 
the  organism  so  that  the  nutrient  material  is  re- 
ceived properly,  and  that  it  is  elaborated  and 
assimilated. 

It  is  absolutely  useless  to  try  to  check  bodily 
decline  by  forced  feeding,  without  paying  atten- 
tion to  the  condition  of  the  digestive  organs  and 
the  general  assimilatory  qualities.  As  soon  as 
the  organism  is  able  physiologically  to  dispose  of 
the  ingesta  the  tide  of  body-decay  is  stemmed  in 
all  those  instances  in  which  some  digestive- 
assimilative  disturbance,  directly  or  remotely, 
stood  at  the  foundation  of  the  malnutrition.  In 
advanced  cachectic  states,  of  course,  when  repa- 
ration of  the  digestive  and  assimilative  functions 
cannot  be  any  longer  accomplished,  body-decline 
will  continue,  uninterruptedly,  as  a  rule. 

We  are  wont  to  consider  a  number  of  chronic 
affections  as  ^^ wasting  diseases."     Such  patho- 


The  Treatment  of  Diabetes  135 

logical  states,  however,  occasion  little  or  no  body- 
waste  so  long  as  the  digestive  and  assimilative 
properties  are  maintained  at  or  near  the  physio- 
logical standards.  In  chronic  ulcerative  phthisis, 
for  instance,  it  is  often  astonishing  how  little  loss 
of  body-substance  has  occurred,  even  in  cases 
which  have  very  far  progressed.  In  such  cases, 
the  inroads  made  by  the  disease  itself  are  in  a 
measure  counteracted  by  the  good  digestion  and 
assimilation. 

The  treatment  of  the  so-called  wasting  diseases 
resolves  itself  in  the  prevention  of  waste.  The 
secret  of  success  in  the  treatment  of  consumptive 
affections  lies  in  the  proper  management  of  the 
organs  of  digestion  and  assimilation.  The  most 
potent  factor  in  maintaining  physiological  diges- 
tion and  assimilation  is  an  adequate  food-supply, 
that  is,  a  nourishment  not  only  sufficient  as  re- 
gards the  quantity,  but  one  which  the  declining 
organism  with  the  weakened  or  impaired  organs 
is  able  to  anabolize,  one,  in  other  words,  which 
furnishes  the  needs  of  the  specifically  affected 
and  altered  organism.  If  the  food  is  not  adapted 
to  the  digestive  and  assimilative  capacity  of  the 
patient,  he  will  slowly  starve,  although  his  food- 
receiving  organs  may  be  filled  ^vith  it  to  the  point 
of  bursting. 

As  a  matter  of  course,  measures  other  than 
dietary  fulfil  a  certain,  more  or  less  important, 
purpose  in  the  management  of  the  condition  of 
subalimentation ;  their  specific  value,  however,  is 


136         Fasting  and  Undernutrition  in 

mostly  of  a  negative,  of  a  defensive  character  so 
to  speak,  as  their  application  does  not  tend  to 
actually  overcome  body-decline  and  much  less  to 
increase  body-weight,  but  to  a  retardation  of 
metabolic  and  catabolic  processes. 

The  most  rational  therapy  for  the  digestive  and 
assimilatory  apparatus  of  the  underfed  as  well 
as  for  the  condition  of  underfed,  is  the  one  in 
which  the  diet  plays  the  most  prominent  role, 
that  is  that  diet  which  is  not  selected  for  the  dis- 
ease but  for  the  individual,  that  diet  which  is 
altered  as  the  patient 's  condition  alters,  that  diet, 
in  short,  which  does  not  call  forth  anorexia, 
sitophobia,  cardiac  irritability,  dyspnea,  or  other 
untoward  phenomena,  but  that  diet  which  is  the 
least  bulky,  the  least  burdensome  to  the  alimen- 
tary organs,  the  richest  in  heat-units,  and  the 
most  potent  protector  of  body  substance. 

In  the  '*yolk  cure"  we  have  a  dietary  regimen 
exhibiting  all  the  advantages  of  a  nutriment  of 
the  first  order  without  its  usual  drawbacks. 

Under  ^^yolk  cure''  I  understand  a  dietary  regi- 
men in  which  the  greater  portion  of  calories  is 
yielded  by  the  yolk  of  the  hen 's  egg,  and  in  which 
the  latter  forms  the  only  fatty  substance.  Be- 
sides this  rigid  **yolk  cure''  we  may  speak  of 
modified  forms  of  the  same.  A  modified  **yolk 
cure"  is  a  dietary  regimen  which  is  either  (a) 
not  a  succession  of  **yolk  days"  (that  is  when 
days  on  which  yolks  do  not  preponderate  in  the 
diet  are  inserted),  or   (h)   when  the  yolks  al- 


The  Treatment  of  Diabetes  137 

though  contained  in  the  diet  in  a  certain  amount, 
do  not  furnish  the  bulk  of  the  calories  and  are  not 
the  sole  representatives  therein  of  the  fatty  in- 
gesta.  In  a  majority  of  instances  a  modified 
**yolk  cure^'  will  be  found  to  offer  certain  advan- 
tages over  the  strict  regimen  when  the  patient's 
alimentary  tract  is  in  good  condition  and  after 
subsidence  of  the  acute  decline,  or  after  the  pa- 
tient has  started  to  gain  in  body-weight.  More- 
over, the  *^yolk  cure,''  modified  according  to  the 
individual  needs  and  desires  and  remodified  from 
time  to  time  in  accordance  with  the  changed  con- 
ditions in  the  organism  is  the  only  means  by 
which  a  yolk  diet  may  be  continued  for  many 
months  and  even  for  years. 

The  yolk  of  the  hen's  egg  in  the  raw  or  half- 
raw  state  is  very  readily  digested.  Experiments 
conducted  by  me  in  the  healthy  human  stomach 
show  that  two  raw  yolks  (slightly  seasoned)  leave 
the  stomach  in  70  to  90  minutes ;  three  in  70  to  100 
minutes;  four,  in  80  to  100  minutes.  One  yolk 
taken  in  hot  water  and  whiskey  leaves  the  stomach 
in  50  to  70  minutes;  two  leave  the  stomach  in  50 
to  75  minutes.  One  yolk  taken  in  a  cup  of  hot 
coffee  (some  sugar,  or  milk)  leaves  the  stomach 
in  60  minutes ;  two  leave  the  stomach  in  60  to  70 
minutes. 

The  *  idiosyncrasy"  for  eggs  which  undoubt- 
edly exists  in  a  number  of  even  healthy  individ- 
uals, in  my  opinion  is  solely  due  to  the  white  of 
the  egg,  I  have  never  found  it  when  the  yolks  only 


138         Fasting  and  Undernutrition  in 

were  partaken  of.  The  white  of  the  egg,  contain- 
ing the  bnlk  of  the  latter 's  protein  substances,  in 
the  face  of  retarded  digestion,  in  gastric  motor 
insufficiency  or  in  any  other  condition  detaining 
the  ingesta  in  the  gastrointestinal  canal,  is  liable 
to  yield  hydrogen  snlphid  and  ammonia ;  the  yolk 
which  is  at  no  time  lodged  in  the  stomach  as  long 
as  the  egg  white,  does  not  exhibit  the  elements 
for  the  production  of  hydrogen  sulphid  to  the  de- 
gree that  the  latter  could  call  forth  any  untoward 
consequences. 

Yolks  are  very  well  assimilated.  This  was 
proved  by  the  comparatively  small  amount  of  fat 
in  the  feces  when  yolks  had  formed  the  exclusive 
fatty  substance  in  the  diet.  It  is  a  known  fact  that 
the  higher  the  melting  point  of  a  fat  the  slower 
and  more  incomplete  will  be  its  assimilation.  The 
raw  yolk,  beaten  up,  being  liquid,  is  quickly  and 
almost  totally  absorbed.  According  to  my  oa\ti 
findings  from  1.5  to  3.5  per  cent,  of  the  yolk-fat 
reappears  in  the  feces.  The  great  absorbability 
of  yolk-fat  will  be  appreciated  when  we  under- 
stand that  milk-fat  reappears  in  the  feces  of  the 
adult  in  the  amount  of  4.4  to  6.6  per  cent.,  and  in 
those  of  the  nursling  in  that  of  5.1  to  7  per  cent. 
The  residue  left  by  yolk- fat  in  the  feces  is  smaller 
than  that  of  any  other  animal  fat. 

Yolks  are  well-borne  and  well-liked  in  almost 
any  amount  by  almost  every  individual.  This 
cannot  be  said  of  any  of  the  other  fatty  ingesta. 
Suet,  lard,  and  tallow  are  not  well  tolerated  by 


The  Treatment  of  Diabetes  139 

the  ordinary  stomach  in  large  amounts  and  cer- 
tainly not  in  quantities  that  yield  the  bulk  of  the 
necessary  heat-units.  A  great  proportion  of  these 
fats,  10, 12,  and  more  per  cent.,  usually  reappears 
in  the  feces.  Olive  oil,  like  all  vegetable  fats,  is 
not  well-borne  in  larger  than  the  ordinary 
amounts.  Besides,  the  individual  of  our  zone 
does  not  easily  develop  a  taste  for  large  quanti- 
ties of  vegetable  oil;  the  acquisition  of  an  aver- 
sion for  it  is  much  more  frequently  the  case. 
Cream  and  butter  are  agreeable  to  the  patient, 
as  a  rule,  but  when  taken  in  amounts  to  furnish 
the  mass  of  body-fuel  they  are  liable  to  decom- 
pose in  the  stomach,  setting  free  thereby  fatty 
acids  of  low  molecular  weight.  These  low  fatty 
acids  tend  to  derange  the  digestive  functions  and 
the  systemic  equilibrium.  Moreover,  they  are  the 
forerunners  of  the  so-called  acetone  bodies  which, 
with  more  or  less  justification,  have  been  brought 
into  casual  relationship  to  the  coma  of  the  dia- 
betic and  various  other,  apparently  autotoxic, 
conditions. 

Furthermore,  the  yolk  of  the  hen's  egg^  as  has 
already  been  sho^^Ti,  contains  a  diastatic  ferment 
assisting  in  the  conversion  of  amyloid  substances. 
It  does  not  exhibit  the  fermentative  qualities  of 
either  the  pancreatic  or  salivary  starch-converting 
enzyme;  its  ferment-properties,  however,  are  im- 
portant nevertheless  and  should  not  be  under- 
estimated. Again,  yolks  are  efficient  stimulators 
of  gastric  secretion  and  may  be  looked  upon  in 


140         Fasting  and  Undernutrition  in 

certain  respects  as  digestants.  They  may  be  par- 
taken of  in  hydrochlorhydria  and  in  all  conditions 
characterized  by  deficient  flow  of  the  gastric  juice. 

That  lecithin  is  contained  in  the  yolks  is  a  fact 
too  well  known  again  to  receive  attention  on  this 
occasion.  The  ingestion  of  yolks  hence  may  tend 
to  the  restoration  of  nerve  force  and  the  ameliora- 
tion of  the  state  of  subalimentation. 

An  average  yolk  of  the  hen's  egg  contains  be- 
tween five  and  six  grams  of  fat,  representing 
about  fifty  calories.  These,  as  we  have  seen,  are 
almost  totally  assimilable  calories.  It  takes, 
therefor,  about  twenty  yolks  to  furnish  one  thou- 
sand and  about  thirty  yolks  to  make  up  fifteen 
hundred  calories.  From  eight  to  twenty  calories, 
yielded  by  yolks,  per  day  and  kilogram  of  body- 
weight,  will  be  found  necessary  in  overcoming 
the  condition  of  the  underfed. 

Yolks  supply  but  very  small  amounts  of  nitro- 
gen. However,  it  is  body-albumin-sparing  in  a 
much  higher  degree  than  any  other  article  of  food 
with  which  I  have  experimented.  Of  course,  the 
excreted  nitrogen  while  under  the  rigid,  unmodi- 
fied *'yolk  cure''  exceeds  that  which  had  been  in- 
gested; the  deficit,  however,  is  so  trifling  that, 
practically,  it  does  not  need  to  be  taken  into  ac- 
count. The  modified  *^yolk  cure,"  on  the  other 
hand,  may  be  so  devised  that  the  patient  remains 
in  nitrogen  balance. 

In  the  preceding  chapter  **  Concerning  the  Sup- 
pression of  the  Acetone  Bodies  in  Diabetics,"  I 


The  Treatment  of  Diabetes  141 

have  already  referred  to  the  ^^yolk  cure''  as  it 
should  be  pursued  in  diabetes  complicated  by 
acetonuria.  I  have  reported  some  cases  in  which 
after  adherence  to  the  specific  regimen  the  ex- 
cretion of  acetone  substances  had  completely 
ceased  and  in  which  the  glycosuria,  at  the  same 
time,  had  diminished  or  vanished  altogether.  In 
all  these  cases,  the  ^^yolk  cure''  had  called  forth 
systemic  and  nutritive  improvement,  and  in- 
crease of  body-weight,  vigor,  and  resistance.  In 
one  of  the  reported  instances,  that  of  a  diabetic 
boy,  15%  years  old,  whom  I  presented  to  the  New 
York  State  Medical  Association,  excreting  very 
large  amounts  of  sugar  and  acetone  substances, 
the  body- weight  increased,  while  under  the  '^yolk 
cure"  from  98i/2  pounds  to  126%  pounds. 

While  in  the  strict  antidiabetic  regimen  carbo- 
hydrates as  well  as  proteins  must  of  necessity  be 
partaken  of  in  more  or  less  restricted  amounts, 
the  *^yolk  cure"  for  the  non-diabetic  underfed 
does  not  take  the  question  of  carbohydrates  and 
proteins  into  consideration.  Quantity  and  quality 
of  each  foodstuff,  however,  have  to  be  determined 
when  treatment  of  the  non-diabetic  underfed  is 
undertaken.  We  should  ascertain  w^hether,  when, 
and  in  what  amounts  a  certain  t^^e  of  food  is 
tolerated  by  the  stomach,  to  what  extent  the  nu- 
tritive substances  are  elaborated  during  the  pro- 
cess of  digestion,  and  what  proportion  of  the 
nutritive  and  calorific  principles  is  utilized  for  the 
general  processes  of  anabolism.     This  is  by  no 


142         Fasting  and  Undernutrition  in 

means  an  easy  task  in  the  majority  of  cases  of 
underalimentation ;  a  minute  study  of  the  individ- 
ual digestive,  elaborative,  and  assimilative  condi- 
tions, however,  is  imperative  if  we  wish  to  aug- 
ment absolute  and  specific  weight  of  the  underfed 
individual.  Simple  clinical  methods  at  the  dis- 
posal of  every  practitioner  enable  him  to  study 
his  patient's  alimentary  qualities  to  the  extent 
that  he  can  prescribe  the  indicated  dietary  regi- 
men in  many  of  the  common  forms  of  malnutri- 
tion. In  other,  rarer,  cases  in  which  clinical 
observation  and  simple  diagnostic  methods  alone 
do  not  afford  sufficient  insight  into  the  alimentary 
conditions,  resort  must  be  taken  to  more  compli- 
cated methods  of  examination  and  determination. 
The  latter,  not  easy  of  execution  in  many  in- 
stances, are  but  rarely  performed  by  the  general 
practitioner. 

One  fact  we  may  be  assured  of,  namely,  that 
the  yolks  are  well-tolerated  by  almost  every 
underfed  individual.  Yolks  hence  are  to  be  the 
basis  of  the  nourishment  of  the  underfed.  It  is 
for  the  clinician  to  determine  in  what  kind  and 
in  how  much  of  a  menstruum  the  yolks  are  to  be 
ingested.  Here  it  is  where  the  difficulty  arises. 
In  some  cases  it  will  be  found  the  yolks  are  best 
administered  in  milk,  coffee,  or  tea.  In  others  in 
the  form  of  a  modified  egg-nog.  Their  beneficial 
effect  in  many  instances  are  only  noticeable  when 
they  are  taken  together  with  certain  carbohy- 
drates in  suitable  amounts.     Taken  in  soup  or 


The  Treatment  of  Diabetes  143 

broths,  together  with  beef,  lamb,  or  chicken,  they 
often  give  rise  to  bodily  improvement  which  does 
not  ensue  in  the  same  degree  when  other  types 
of  ingesta  serve  as  vehicles.  Again,  in  other 
cases,  especially  in  those  of  pulmonary  tubercu- 
losis, an  ordinary  mixed  diet  in  which  the  fat 
substances  are  merely  replaced  by  the  yolks,  is 
frequently  all  that  is  necessary  to  stimulate  the 
assimilative  properties  and  to  cause  increase  of 
w^eight,  vigor,  and  resistance. 

If  a  patient  who  is  not  in  the  last  stages  of  a 
consumptive  affection,  does  not  gain  in  body- 
weight  while  he  is  under  the  ^^yolk  cure,"  the 
latter  as  a  rule  is  not  properly  executed,  that  is, 
the  food  which  is  partaken  of  together  with  the 
yolks  is  either  not  the  right  kind  or  is  ingested 
in  amounts  not  suited  to  the  alimentary  condi- 
tion. A^Tiile  the  proper  kind  of  nutriment  favors 
the  specific  yolk  action,  food  wrong  in  character 
or  amount,  or  in  both,  retards  or  suppresses  the 
absorption  of  the  yolk  constituents. 

On  the  other  hand,  the  yolks  facilitate  the 
digestion  of  certain  amounts  of  carbohydrates 
(diastatic  ferment)  and  that  of  comparatively 
large  quantities  of  proteins  (stimulation  of  gas- 
tric secretion).  They  do  not  seem  to  possess 
properties  which  render  other  fats  added  to  the 
food  easy  of  absorption.  Again,  impaired  fat 
absorption  appears  to  be  directly  responsible  for 
the  underfed  state  in  a  rather  large  percentage 
of  cases.    As  experience  (fecal  examination)  has 


144         Fasting  and  Undernutrition  in 

shown  me  that  yolks  are  almost  as  completely  ab- 
sorbed in  most  instances  of  disease  followed  by 
loss  of  body- weight  (in  not  too-far  advanced 
stages)  as  they  are  in  the  normal  individual,  all 
fatty  substances  in  the  food  should  be  replaced 
as  completely  as  possible  by  yolks.  When  im- 
provement has  ensued,  it  might  not  be  necessary 
to  insist  upon  yolks  as  the  sole  fatty  nutrients  in 
all  instances ;  some  other  fats,  in  limited  amounts, 
may  be  added  to  the  diet  or  what  seems  more 
rational,  one  or  more  days  on  which  the  yolks  do 
not  form  an  important  part  in  the  diet  but  on 
which  the  common  fat  substances  are  ingested  in 
limited  amounts,  may  be  intercalated  every  week. 
On  the  other  days,  however,  the  yolks  should  con- 
tinue to  furnish  the  bulk  of  the  heat-units  or  at 
least  they  should  form  the  sole  fatty  matter  enter- 
ing the  organism  with  the  diet. 

A  sample  of  a  yolk  menu  destined  for  a  con- 
sumptive weighing  110  pounds  (50  kilograms) 
whose  normal  weight  ought  to  be  140  pounds 
(63.63  kilograms)  but  whose  alimentary  system 
admits  the  ingestion  of  some  carbohydrates  and 
of  almost  normal  amounts  of  proteins,  is  given 
in  the  following.  This  patient  should  obtain  food 
to  the  value  of  35  calories  per  day  and  kilogram 
of  body-weight,  that  is  1,750  calories  in  the 
twenty-four  hours. 


The  Treatment  of  Diabetes  145 

Calories 

yielded        Total 

Number   by  yolks,  calories 

of  approx-  approx- 

yolks.       imately.  imately. 

Breakfast — 250  c.c.  skim  milk  with  4  yolks  4           200           290 

30  grams  wheaten   toast 75 

Early  lunch— Cup  of  coffee,  2  yolks 2           100           100 

Dinner — One  plate  of  soup,  4  yolks 4           200           225 

Beef,  very  lean,  150  grams 125 

30  grams  wheaten  toast 75 

4  o'clock — 250  c.c.  skim  milk,  30  c.c.  whis- 
key, 3  yolks 3           150          370 

Supper — Porridge   of   farina  or   rice,    100 

grams,  1  yolk,  skim  milk 1             50           350 

Apple  sauce,  75  grams 30 

At  bedtime — Xight  cap  (90  c.c.  hot  water, 
10   c.c.    whiskey,    1    yolk,   teaspoonful 

granulated  sugar)    1             50           110 

Total     15  750        1,750 

In  a  prolonged  yolk  diet,  the  proportion  of  the 
various  types  of  nutritives  may  and  must  be  al- 
tered according  to  the  prevailing  alimentary  cir- 
cumstances; a  dietary  as  outlined  in  the  forego- 
ing, however,  may  be  looked  upon  as  a  standard 
in  the  suitable  cases.  The  whole  eggs  may  be 
well  tolerated  in  certain  cases.  When  whole  eggs 
are  employed  extra  yolks  may  be  added  to  them. 
In  order  to  avoid  monotony  and  aversion,  the 
latter  being  invariably  the  consequence  of  the 
long-continued  use  of  the  same  kind  of  meat  or 
of  the  same  kind  of  farinaceous  material,  a  va- 
riety of  dishes  in  which  yolks  may  be  incorporated 
should  be  devised. 

All  yolk  dishes  must  contain  salt  in  sufficient 
amounts.      Flavoring  and  seasoning  substances 


146         Fasting  and  Undernutrition  in 

may  be  added  to  the  various  articles  of  food  as 
long  as  there  is  no  contraindication  to  their  em- 
ployment ;  it  should  always  be  borne  in  mind  that 
spices  are  not  inert  substances  and  that  their  use 
may  as  well  retard  as  increase  digestive  activity, 
as  the  case  may  be.  As  a  general  rule,  patients 
under  the  **yolk  cure"  are  not  subject  to  consti- 
pation. Mild  laxatives  may  be  employed  in  cases 
tending  to  this  condition. 

The  **yolk  cure"  in  its  various  modifications 
has  nothing  in  common  with  the  legion  of  un- 
natural and  irrational  feeding  systems  extolled 
here,  there,  and  everywhere.  It  is  not  a  fad  with 
me  and  I  hope  it  will  not  become  one  with  others. 
It  has  its  limitations,  to  be  sure,  but  if  conscien- 
tiously employed  in  certain  forms  of  malnutri- 
tion, it  will  increase  the  body-weight  and  restore 
bodily  resistance  when  other  dietary  regimes  have 
proved  decided  failures. 

Reference 
10  Who  is  Underfed?    Medical  Record,  May  21,  1904. 


The  Treatment  of  Diabetes  147 

V 

The  Fat  Question  in  Its  Relation  to  the 

Production  and  Cure  of  Infantile 

Marasmus 

It  is,  of  course,  well  understood  that  infantile 
marasmus,  like  any  other  condition  of  underas- 
similation,  is  not  the  consequence  of  the  self-same 
primary  cause  in  every  instance.  As  a  matter  of 
fact,  however,  food  physically,  chemically  or  bio- 
logically unsuited  to  the  needs  of  the  delicate 
infantile  organism  is  the  most  frequent  instigator 
of  the  gastro-intestinal  disturbances,  which  again 
are  the  usual  forerunners  of  athrepsia  infantum. 

In  breast-fed  infants,  pronounced  marasmic 
conditions  are  of  comparatively  infrequent  oc- 
currence; in  the  overwhelming  majority  of  in- 
stances, wasting  and  atrophy  supervene  in  bottle- 
fed,  that  is,  in  artificially  nourished,  children. 
Milk  modifications  and  suJ^stitutes,  purporting  to 
replace  the  physiologic  nutriment,  are  numerous ; 
some  are  fairly  rational,  but  a  majority  ad  nau- 
seam to  the  earnest  seeker  of  truth  and  still  more 
so  to  the  helpless  babe,  have  sprung  into  the  field 
in  the  last  twenty-five  years. 

Frequently,  no  doubt,  the  onset  of  athrepsia 
infantum  has  been  averted  by  one  of  the  more 
rational  milk  modifications  or  substitutes;  but 
this  peculiar  state  of  undernutrition  is  met  with 
by  the  clinician  of  today  in  at  least  the  same 


148         Fasting  and  Undernutrition  in 

proportional  numbers  as  was  seen  by  his  prede- 
cessor twenty  and  thirty  years  ago.  Further- 
more, when  infantile  atrophy  has  once  ensued, 
none  of  all  the  milk  modifications  or  food  prepa- 
rations so  far  devised,  and  for  that  matter  not 
even  good  breast  milk,  seems  to  possess  any  spe- 
cial virtues  in  checking  the  wasting. 

I  have  no  intention  whatsoever  to  thresh  over 
old  straw,  and  I  am  loath  to  sit  in  judgment  on 
the  multitude  of  formulas  for  the  attenuation  and 
modification  of  cow's  milk  or  the  various  methods 
of  artificial  infant  feeding.  However,  I  wish  to 
dwell  on  a  much  neglected  point  in  infant  feeding, 
a  factor  which  may  be  at  the  foundation  of  many 
an  instance  of  athrepsia  infantum.  This  factor 
is  the  chemical  character  of  the  fatty  substances 
contained  in  the  baby's  nutriment. 

While  the  quantity  of  the  fat  aliment  has  found 
frequent  practical  consideration  (Biedert's  Cream 
Mixture,  Gartner's  Fat  Milk,  etc.),  its  quality — 
apart  from  various  minor  attempts  at  modifying 
the  fat  of  cow's  milk  which,  physically  and  chemi- 
cally, differs  widely  from  that  of  mother's  milk — 
has  hardly  ever  been  taken  into  account  when  de- 
vising a  food  for  the  healthy  and  particularly  for 
the  diseased  and  undernourished  infant. 

The  fat  of  mother's  milk,  of  course,  is  and 
should  be  the  physiologic  fat  aliment  of  the 
normal  nursling;  properly  constituted  and  in 
amounts  suitable  to  the  needs  of  the  individual 
infantile  organism,  it  does  not  yield  low  fatty 


The  Treatment  of  Diabetes  149 

acids  to  the  extent  of  calling  forth  intestinal  or 
other  disturbance  and  is  absorbed  and  anabolized 
in  quantities  guaranteeing  normal  growth  and  de- 
velopment. Production  and  secretion  of  the  fat 
substances  in  human  milk,  however,  occur  not 
always  in  the  same  ratio,  and  their  composition 
may  vary  considerably.  As  long  as  quantity  and 
quality  of  the  fatty  components  of  mother's  milk 
fluctuate  between  physiologic  limits,  normal  fat 
decomposition  and  assimilation  will  not  be  inter- 
fered with,  and  unless  there  exists  some  anomaly 
of  the  other  milk  constituents,  or  a  bodily  insuffi- 
ciency or  a  pathologic  condition,  the  development 
of  the  baby — although  progressing  but  slowly  at 
times — continues  uninterruptedly  as  a  general 
rule. 

On  the  other  hand,  if  for  protracted  periods 
the  fat  substances  of  mother's  milk  occur  in  dis- 
tinctly abnormal  amounts,  or  in  a  less  perfect 
emulsion,  or  if  they  are  perverse  in  admixture 
or  composition,  gastro-intestinal  disturbances,  ac- 
companied by  severe  metabolic  irregularities  or 
by  toxic  phenomena  and  terminating  in  bodily  de- 
cline and  atrophy,  will  supervene  sooner  or  later. 
If  permitted  to  run  for  any  length  of  time,  this 
wasting  condition  cannot  always  be  checked  and 
a  fatal  termination  be  averted,  in  instances  even 
where  the  fatty  principles  of  the  mother's  milk 
have  meanwhile  been  excreted  in  normal  amounts 
and  composition,  or  in  which  the  child  has  been 
fed  on  the  milk  of  another  woman. 


150         Fasting  and  Undernutrition  in 

Happily,  extreme  alterations  in  the  amount  and 
especially  in  the  composition  of  the  fat  of  the 
milk  of  a  healthy  woman  do  not  ensue  very  often, 
and  therefore  a  pronounced  marasmic  condition 
obtains  comparatively  rarely  in  the  (at  birth 
normal)  breast-fed  child. 

In  artificial  nutrition,  no  matter  whether  a 
modification  of  cow's  milk  or  a  food  preparation 
is  utilized,  the  entire  fatty  principles  are,  as  a 
rule,  derived  from  the  cream  of  cow's  milk. 

The  fat  of  cow's  milk,  it  is  true,  may  be  added 
to  the  food  mixture  in  any  desired  amount;  its 
composition,  however,  is  liable  to  vary  to  a  far 
greater  extent  than  that  of  the  fat  of  human  milk, 
it  being  dependent  on  the  breed  and  race  of  the 
animal,  its  individual  characteristics,  its  age,  how 
often  it  has  calved,  the  time  of  lactation,  the  hour 
of  milking,  the  season,  quantity  and  quality  of 
food,  etc.  Besides,  and  this  is  a  fact  but  insuffi- 
ciently expounded,  the  composition  of  the  fat  of 
cow's  milk  is  at  variance  with  that  of  the  fat  of 
human  milk,  differing  especially  in  its  far  greater 
contents  of  volatile  fatty  acids,  among  which  buty- 
ric acid  is  the  most  important.  In  the  following 
table  the  discrepancies  in  the  constitutions  and 
proportion  of  the  fats  of  mother's  and  cow's  milk 
are  quickly  recognized: 

PHYSICAL   CHARACTERS 

Fat  of  Mother' s  Milk.     Fat  of  Cow's  Milk. 

Specific  gravity  at  15  deg.  C.  0 .  966  0 .  949  -  0. 946 

Melting  point 30-34  deg.  C.      31.1  -  34.66  deg.  C. 

Solidifying  point 19-22.5  deg.  C.  35  -  38  deg.  C. 


The  Treatment  of  Diabetes 


151 


CHARACTER   AND   PROPORTION    OF    FATTY   ACIDS 


Acid 


butyric,  C4H8O2 
caproic,  C0H1JO2 
caprylic,  C8H1CO2 
capric,  C1UH20O2 
lauric,  C12H24O2 
myristic,  C14H28O2 
palmitic,  C16H32O2 
stearic,  C1SH36O2 
dioxystearic,  C18H36O4 
oleic,  C18H34O2  49.4 


1.4 


49.2 


5.45 
2.09 
0.49 
0.32 
2.57 
9.89 

38.61 
1.83 
1.04 

32.5 


8.35 


53.90 


Very  small  amount  of 
volatile  fatty  acids;  oleic 
acid  forms  one-half  of  the 
non-volatile  acids ;  of  the 
solid  fats,  myristic  and  pal- 
mitic acids  occur  in  larger 
amounts  than  stearic  acid. 


Volatile  acids  according: 
to  other  analyses  about  10 
per  cent.  ;  among-  the  solid 
acids  palmitic  and  stearic 
acids  preponderate. 


If  we  remember  that  mother  ^s  milk  usually  ex- 
hibits a  somewhat  larger  percentage  of  fat  sub- 
stances than  cow's  milk — on  the  average  3.85  per 
cent,  in  the  former  and  3  per  cent,  in  the  latter — 
and  that  in  order  to  compensate  for  the  apparent 
deficiency,  hand-fed  children  frequently  obtain 
the  fatty  elements  of  cow's  milk  in  larger  propor- 
tion than  they  exist  in  the  native  product,  we 
understand  that  the  absolute  discrepancy  of  the 
fat  as  it  is  given  to  the  infant  is  even  greater  than 
its  relative  discrepancy  as  pointed  out  in  the 
table.  An  extra  amount  of  fat  of  cow's  milk 
added  to  the  child's  food  enhances  the  latter 's 
contents  of  volatile  fatty  acids.  Thus,  in  prac- 
tice, the  discrepancy  in  the  proportion  of  the 


152         Fasting  and  Undernutrition  in 

fatty  substances  may  even  become  a  greater  one.* 
It  is  evident  that  a  fat-compound  consisting  of 
10  per  cent,  of  volatile  acids  cannot  be  a  rational 
substitute  for  a  fatty  nutrient  into  the  composi- 
tion of  which  these  volatile  acids  enter  in  but 
comparatively  small  amounts.  The  most  impor- 
tant of  these  volatile  fatty  acids  is  butyric  acid, 
whose  very  presence  in  the  fat  of  human  milk  has 
been  denied  by  some  investigators. 

At  any  rate,  the  proportion  in  which  it  nor- 
mally occurs  in  the  fat  of  mother's  milk  is  so 
small  that  any  untoward  action  on  its  part  has  to 
be  precluded.  When  it  is  exhibited  in  propor- 
tionally larger  amounts  for  any  length  of  time— 
a  rare  but  always  pathologic  event — the  human 
milk  in  which  it  is  contained  sooner  or  later 
ceases  to  contribute  to  the  welfare  of  the  nursling. 
Inasmuch  as  the  fat  of  cow's  milk  always  dis- 
plays a  large  quantity  of  butyric  acid,  and  as  this 
is  the  mother  substance  of  the  acetone  bodies,  the 
former  would  a  priori  not  represent  the  ideal 
type  of  fatty  nutriment  for  the  infant.  Besides 
this,  the  infantile  organism  is  not  particularly 
well  adapted  for  the  fat  compound  derived  from 
cow's  milk;  it  being  unable  to  cope  successfully 

*It  must  also  not  be  lost  sight  of  that  in  human  milk  the 
fat  is  in  a  much  finer  state  of  emulsifieation  than  in  cow's  milk, 
which  facilitates  its  direct  absorption.  Tliis  is  of  great  impor- 
tance, as  there  are  in  the  infantile  organism  but  insufficient 
amounts  of  biliary  acids,  and  pancreatic  development  and  function 
are  as  yet  not  far  progressed. 


The  Treatment  of  Diabetes  153 

with  it  even  in  a  mere  physical  sense.  This  is 
evinced  by  the  smaller  absorption  of  the  fat  of 
cow's  milk.  Uffelmann^^  determined  that  the  ab- 
solute amount  of  fecal  fat  after  the  nse  of 
mother 's  milk  was  normally  about  half  that  when 
cow's  milk  had  been  the  nutriment  (in  the  dried 
feces  0.8-0.9  gram  fat  per  diem  after  cow's  milk, 
0.44  gram  after  mother's  milk).  A  larger  excre- 
tion of  fat  of  cow's  milk  than  of  human  milk, 
although  not  in  as  pronounced  a  disproportion  as 
in  the  normal  state,  occurs  also  in  pathologic  con- 
ditions of  the  digestive  tract. 

The  occurrence  in  the  feces  of  absolutely  and 
relatively  larger  amounts  of  fat  of  cow's  milk  is 
prima  facie  evidence  of  its  more  incomplete  utili- 
zation by  the  youthful  organism.  As  a  matter  of 
fact,  however,  the  fat  of  mother's  milk  is  also  in- 
completely absorbed,  the  fat  contents  of  dry  feces 
when  mother's  milk  is  the  habitual  food  fluctuat- 
ing between  10  and  20  per  cent.  The  younger  the 
infant  the  larger  the  amount  of  non-absorbed 
fat.  The  dried  feces  of  infants  during  the  first 
week  of  life,  according  to  Blauberg  (Die  Faeces, 
Schmidt  und  Strasburger,  1903),  contain  40  per 
cent,  of  fat  when  mother's  milk,  and  fully  50  per 
cent,  when  cow's  milk  has  been  ingested.  The 
fecal  fat,  surplus  fat,  as  it  has  been  called  by 
some,  which  is  found,  though  in  wddely  varying 
quantities,  in  all  conditions  possibly  has  to  fulfil 
a  certain  mission.  Maybe  it  is  essential  for  a 
better  evacuation  of  the  infants'  bowels,  maybe 


154        Fasting  and  Undernutrition  in 

it  acts  as  a  protector  of  the  intestinal  mucosa, 
maybe  its  purpose  is  a  different  one  altogether. 
This  much  we  may  put  down  as  an  irrefutable 
fact:  The  more  the  fat  output  by  the  feces  ap- 
proaches the  minimum  figure  for  each  period  of 
infant  life — provided  normal  amounts  of  food  ex- 
hibiting a  proper  ratio  of  fats  have  been  ingested 
— the  better  the  gastro-intestinal  organs  perform 
their  work,  the  healthier  the  youthful  organism, 
the  brighter  the  outlook  for  its  normal  develop- 
ment. 

However,  I  wish  to  dwell  on  the  character  and 
not  on  the  amount  of  the  fatty  substances.  The 
volatile,  soluble  fatty  acids,  those  which  are  more 
or  less  soluble  in  hot  water  whereby  their  mole- 
cular weight  diminishes  and  which  include  those 
members  of  the  fatty  acid  series  up  to  capric  acid, 
occur,  as  we  have  seen,  in  unusually  large  amounts 
in  the  fat  of  cow's  milk.  Butyric,  caproic,  capry- 
lie  and  capric  acids  are  contained  in  the  fat  of 
cow's  milk  in  from  six  to  eight  times  the  quantity 
in  which  they  are  present  in  that  of  human  milk. 
As  the  physical  and  chemical  properties  of  the 
milk- fat  are  dependent  upon  the  absolute  and 
relative  amount  of  lower  and  higher  and  uncom- 
bined  fatty  acids,  it  is  evident  that  such  a  vast 
discrepancy  as  that  existing  between  the  consti- 
tution of  cow's  milk- fat  and  mother's  milk-fat, 
cannot  be  overcome  by  any  possible  modification 
of  the  former. 

Milk  fat,  chemically  speaking,  is  a  compound 


The  Treatment  of  Diabetes  155 

of  mixed  glycerin  esters  and  not  a  simple  mixture 
of  triglycerides.  According  to  Volhard^^  ^  cer- 
tain degree  of  decomposition  of  the  neutral  milk 
fat  into  glycerin  and  fatty  acid  occurs  already  in 
the  stomach.  The  neutral  fats  very  likely  un- 
dergo hydrolytic  decomposition  and  are  rendered 
soluble  partly  by  saponification  and  partly  (as 
fatty  acids)  by  the  action  of  the  bile.  Inasmuch 
as  almost  the  entire  fat  contained  in  the  thoracic 
duct  occurs  as  neutral  fat  in  the  form  of  a  fine 
emulsion,  while  acids  and  soaps  are  present  in 
minute  quantities  only,  we  are  forced  to  conclude 
that  a  reconversion  into  neutral  fats  must  take 
place  in  the  intestinal  wall.  The  fat  in  the  intes- 
tinal tract  of  the  ingested  volatile  fatty  acids  is 
probably  similar  to  that  of  oleic  acid  and  the 
higher  members  of  the  fatty  acid  series.  Noth- 
ing definite,  however,  is  known  in  this  respect. 
The  volatile  fatty  acids  appearing  in  the  feces  do 
not  ofPer  any  information  in  this  regard,  as  they 
are  practically  always  the  result  of  carbohydrate 
fermentation  in  the  intestines;  likewise,  no  ade- 
quate explanation  is  afforded  by  the  urinary  vola- 
tile fatty  acids,  as  oxybutyric  acid  and  its  con- 
comitants and  derivatives  which,  in  the  opinion 
of  some  of  the  more  recent  investigators,  are 
products  of  an  incomplete  oxidation  of  the  fatty 
acids  of  higher  molecular  weight.  That  this  is 
not  always  the  case,  even  not  when  these  acids 
appear  in  pathologic  amounts,  I  think  I  have  con- 
clusively sho^oi  by  the  dieto-therapeutic  test.  (See 


156         Fasting  and  Undernutrition  in 

Chapter  III  of  Part  II,  **The  Suppression  of 
Acetone  Bodies  in  Diabetics/') 

Acetone  of  supposedly  intestinal  formation  has 
not  infrequently  been  accused  of  being  the  pro- 
moter of  periodical  vomiting  in  children,  of  in- 
fantile eclampsia  and  of  numerous  other  affec- 
tions to  which  the  young  child  is  prone.  Be  this 
as  it  may,  of  one  fact  we  may  be  certain,  that 
butyric  acid  in  quantities  sufficient  to  furnish 
large  amounts  of  acetone  substances  cannot  have 
been  yielded  by  carbohydrates  or  proteins,  but 
must  have  been  ingested  as  such.  What  is  nearer 
than  to  assume  that  the  fat  of  cow's  milk,  which 
contains  abundant  butyric  acid,  is  the  real  insti- 
gator of  a  number  of  pathologic  affections  which 
with  little  justification  have  been  ascribed  to  an 
autotoxic  origin. 

Turning  from  the  acetone  question  which,  in  its 
relation  to  various  infantile  disturbances,  offers 
a  field  of  fertile  discussion,  and  even  more  of  vast 
speculation,  we  find  that  the  volatile  fatty  acids 
as  furnished  by  the  fat  of  cow's  milk  are  very 
decided  irritants  of  the  delicate  intestinal  mucosa 
of  the  infant.  The  ingestion  of  these  acids  is 
therefore  the  primary  cause  of  many  instances  of 
gastro-intestinal  irritation  and  disease  followed 
by  undernutrition,  bodily  retrogression  and 
athrepsia  infantum. 

Gastro-intestinal  irritation  once  set  up,  pro- 
gresses rapidly  wher^  the  nutriment  is  not 
changed,  that  is,  in  those  instances,  when  the  sup- 


The  Treatment  of  Diabetes  157 

ply  of  fat  is  not  materially  altered.  The  altera- 
tion in  the  fat  supply  as  exercised  today  being 
almost  without  exception  a  quantitative  one,  con- 
sisting of  reduction,  suspension  and  even  in- 
creased supply  of  fat  aliment — it  is  obvious  that 
an  improvement  in  the  little  patient's  local  and 
general  condition,  when  fhe  fatty  constituents  of 
the  nourishment  are  at  the  foundation  of  the  dis- 
turbance, is  always  more  or  less  a  matter  of  luck. 
No  doubt  the  proteins  and  carbohydrates  of 
cow's  milk  or  artificial  foodstuffs  quantitatively 
and  to  a  greater  degree  qualitatively,  also  stand 
frequently  at  the  bottom  of  the  gastro-intestinal 
disturbance,  which,  of  course,  gives  occasion  to 
the  development  of  infantile  atrophy.*  Their 
eventual  unsuitability,  however,  is  a  matter  of 
general  information,  while  the  inadequacy  of  the 
fat  of  cow's  milk  in  the  feeding  of  babes  is  known 
to  comparatively  few  clinicians.  It  is  true,  they 
often  withhold  the  milk  totally  in  certain  affec- 
tions of  the  gastro-intestinal  tract,  to  which  fact 
the  speedy  recovery  of  the  infant  is  undoubtedly 
to  be  ascribed,  yet  they  are  not  aware  that,  in  the 
given  instance,  neither  proteids  nor  carbohy- 
drates, nor  eventual  superabundance  of  bacteria, 
but  the  fatty  constituents  of  the  milk  furnished 
the  source  of  the  pathologic  condition  or  pre- 
vented its  amelioration. 

*  It  is  not  improbable  that  the  greater  amount  of  citric  acid 
and  inorganic  saUs  contained  in  cow's  milk  exert  an  unfavorable 
influence  upon  the  digestive  tract,  the  osmotic  conditions  and  the 
nutrition  of  the  infantile  organism. 


158         Fasting  and  Undernutrition  in 

While  witlidrawal  of  milk-fat  in  liand-fed  in- 
fants may  frequently  result  in  cessation  of  the 
local  disturbance,  it  is  obvious  that  the  infant 
cannot  exist  for  any  length  of  time  without  fatty 
ingesta  of  some  kind.  Again,  the  incipient  maras- 
mic  condition,  or  that  already  established,  can- 
not be  relieved  unless  a  sufficient  amount  of  as- 
similable fats,  yielding  but  insignificant  amounts 
of  volatile  fatty  acids,  is  added  to  the  nutriment. 
Vegetable  oils  and  those  animal  fats  exhibiting  a 
high  melting  point  being  out  of  question,  there  is 
nothing  left  for  us  but  to  resort  to  the  fats  fur- 
nished by  the  yolk  of  the  hen's  egg.  Yolk-fat, 
indeed,  is  the  ideal  fat  for  infants  suffering  from 
chronic  gastro-intestinal  disturbances,  together 
with  latent  or  even  pronounced  athrepsia  in- 
fantum. 

It  would  lead  me  too  far  to  dwell  again  on  the 
peculiar  adaptability  of  the  yolk  of  the  hen's  egg 
in  the  treatment  of  various  forms  of  malassimila- 
tion.  On  this  occasion  I  only  wish  to  reiterate 
some  of  the  factors  which  prompted  me  to  sub- 
stitute yolks  for  milk-fat  in  the  treatment  of 
undernourished  infants  afflicted  with  gastro-intes- 
tinal disease. 

I.  Yolk-fat,  in  its  native  state,  in  suitable 
amounts  and  admixture,  is  well-borne  and  well- 
liked  by  the  majority  of  infants. 

II.  The  great  absorbability  of  yolk-fat;  the 
residue  left  by  yolk-fat  in  the  feces,  is  smaller 
than  that  of  any  other  animal  fat. 


The  Treatment  of  Diabetes  159 

III.  The  fat-components  of  the  yolk  of  the 
hen's  egg^  palmitin,  stearin  and  olein,  yield  no, 
or  hardly  any,  volatile  fatty  acids,  and  conse- 
quently give  no  occasion  to  the  production  of  the 
acetone  bodies. 

IV.  The  large  amount  of  lecithin  contained  in 
the  yolk  tends  to  the  restoration  of  nerve  force, 
and  acting  as  a  general  reconstituent  ameliorates 
the  cachectic  condition. 

V.  The  occurrence  in  the  yolk  of  a  diastatic 
ferment  assisting  in  the  conversion  of  amyloid 
substances. 

VI.  The  property  of  the  yolk  to  stimulate  the 
digestive  secretions. 

The  entire  egg  has  been  frequently  employed 
by  the  pediatrist,  the  yolk  alone  but  rarely. 
There  is  no  consensus  of  opinion  as  regards  the 
digestibility  of  the  whole  egg  in  the  infantile  ali- 
mentary tract.  Some  extol  the  egg  as  an  impor- 
tant and  readily  digestible  nutrient  in  early  life, 
while  others  are  absolutely  opposed  to  its  utili- 
zation. 

Monti,  who  belongs  to  the  latter  class,  deems 
it  possible  that  the  employment  of  storage-eggs 
to  a  certain  extent  may  be  responsible  for  his 
personal  adverse  opinion.  He  thinks  that  it  is 
always  risky  to  give  eggs  to  children  before  they 
are  weaned,  as  digestive  disturbances  are  likely 
to  be  set  up  in  the  majority  of  instances. 

There  is  no  doubt  that  the  total  egg  is  badly 
borne  by  the  average  nursling.      This  finds  its 


160         Fasting  and  Undernutrition  in 

analogue  in  a  certain  proportion  of  healthy  adults 
who  have  an  *  idiosyncrasy''  for  eggs.  The  in- 
dividual constitutional  aversion  to  eggs  in  my 
opinion  is  solely  due  to  the  white  of  the  egg,  I 
have  never  met  with  it  when  raw,  fresh  yolks 
alone  were  partaken  of.  The  white  of  the  egg, 
which  exhibits  the  bulk  of  the  latter 's  protein 
substances,  is  apt  to  yield  undue  amounts  of  hy- 
drogen sulphid  and  ammonia.  This  is  particu- 
larly liable  to  occur  in  instances  of  retarded 
digestion  of  whatever  causation.  The  yolk  as 
previously  shown  leaves  the  stomach  in  a  very 
short  time  and  does  not  contain  the  elements  giv- 
ing rise  to  such  amounts  of  hydrogen  sulphid  that 
it  could  produce  any  untoward  results.  A  mix- 
ture of  yolks  with  water  and  sugar,  which  has 
been  recommended  as  a  food  for  the  newborn,  is 
rightfully  condemned  by  Monti.  Such  a  combina- 
tion is  in  the  first  instance  irrational  in  itself, 
and  there  is  no  reason  whatsoever  why  it  should 
be  given  as  a  nutriment  to  the  normal  infant  when 
it  first  enters  life. 

It  must  be  understood  once  for  all  that  yolks 
should  neither  find  employment  in  the  newborn 
nor  in  the  infant  which  thrives  on  the  physiologi- 
cal nutriment  or  on  a  modification  of  cow's  milk. 
I  suggest  the  use  of  yolks  only  in  such  pathologic 
conditions  which  may  lead  to  athrepsia  infantum, 
and  which  are  due  to  or  aggravated  by  the  fat 
constituents  of  the  nourishment. 

There  are  two  essentials  which  must  be  fol- 


The  Treatment  of  Diabetes  161 

lowed  when  good  shall  result  from  the  ingestion 
of  yolks. 

First. — The  yolk-fat  must  completely  replace 
the  milk-fat. 

Second, — The  amount  of  yolk-fat,  without  being 
in  excess,  must  be  adequate,  that  is,  it  must  con- 
form to  the  caloric  and  nutritive  demands  of  the 
organism. 

The  first  essential  is  self-evident.  By  with- 
holding the  milk-fat  from  the  nutriment  we  re- 
move the  eventual  etiologic  or  aggravating  fac- 
tor of  the  underlying  disease,  or  a  fat-compound 
which,  in  the  specific  instance,  has  demonstrated 
its  inadequacy  in  supplying  the  systemic  de- 
mands. Substituting  for  it  yolk-fat,  we  furnish 
to  the  deteriorated  or  diseased  infantile  organ- 
ism a  fat-combination  which  does  not  yield  buty- 
ric acid  or  its  derivatives,  and  which  it  is  able  to 
be  anabolized  in  the  great  majority  of  instances. 
Cod-liver  oil,  empirically  prescribed  for  under- 
nourished children  since  time  immemorial,  al- 
though frequently  serving  a  good  purpose,  will 
never  be  considered  part  and  parcel  of  the  in- 
fants' nutriment,  and  does  not  bear  comparison 
with  the  yolk-fat  as  a  dietetic  factor.  Untoward 
results  obtained  by  yolks  in  the  treatment  of  the 
undernourished,  and  more  especially  of  athrepsia 
infantum,  in  a  great  measure  are  due  to  the  non- 
withdrawal  from  the  nourishment  of  the  mischie- 
vous milk-fat. 

The   second  essential — for  all  practical  pur- 


162         Fasting  and  Undernutrition  in 

poses — is  readily  executed.  A  marasmic  infant, 
in  spite  of  abundant  milk-fat,  may  continue  to 
decline.  It  is  evident,  therefor,  that  the  child 
does  not  properly  anabolize  the  fatty  substances 
introduced  by  the  milk-fat.  When  this  is  replaced 
by  another  fat-compound,  as  yolk,  for  instance, 
it  is  not  the  amount  of  the  latter  but  its  physico- 
chemical  constitution  and  its  absorbability  which 
primarily  count.  A  very  small  amount  of  yolk, 
probably  a  quarter  of  a  teaspoonful  for  each 
feeding,  may  be  all  that  is  needed  when  the  change 
is  first  made.  No  matter  how  little  of  the  proper 
fat-compound  is  ingested  it  serves  a  better  pur- 
pose than  a  superabundance  of  the  wrong  fatty 
material.  Even  if  during  the  first  two  or  three 
weeks  of  yolk  administration  the  child  holds  but 
its  o-wii,  we  have  an  indication  that  active  decline 
has  been  checked  for  the  time  being.  In  every- 
day practice  all  that  seems  necessary  when  re- 
sorting to  yolk-fat  in  the  dietetic  management  of 
marasmic  children  is  to  start  with  aforemen- 
tioned quantity  and  to  very  slowly  increase  it  to 
the  physiologic  requirements  of  each  individual 
case.  The  physiologic  demands  are  satisfied  when 
the  digestive  disturbance  abates  and  the  infantile 
organism  thrives  in  a  normal  manner.  These  re- 
quirements, of  course,  are  different  in  every  in- 
stance and  have  to  be  ascertained  in  each  individ- 
ual case. 

The  fat-compound  **yolk"  differs  widely  from 
the  fat-compound  ** cream."    Again,  amount  and 


The  Treatment  of  Diabetes  163 

proportion  of  the  fatty  contents  of  the  yolk  are 
changeable  as  they  are  in  the  mammary  secretion 
of  the  woman  and  the  domesticated  animals. 
Hence,  the  corresponding  caloric  and  nutritive 
value  of  both  fat-compounds  cannot  be  accurately 
calculated. 

The  petroleum-ether  extract  of  the  yolk,  ac- 
cording to  Jean  {Annal.  de  Chimie  Analyt,,  8), 
amounts  to  48.24  per  cent. ;  the  average  quantity 
of  fat  in  cream  is  about  20  per  cent.  An  average 
yolk  weighing  about  12.5  grams,  hence,  contains 
about  6  grams  of  fat.  The  same  amount  of  fat  is 
exhibited  in  31.25  c.c.  of  cream.  Eoughly  speak- 
ing, an  ounce  of  cream  would,  therefore,  corre- 
spond to  one  yolk  as  regards  their  fatty  contents, 
and  a  teaspoonful  of  yolk  (4  grams)  and  10  c.c. 
of  cream  would  contain  about  equal  amounts 
of  fat. 

A  1-per-cent.  fat  mixture  is  furnished  approxi- 
mately by  5  c.c.  cream,  or  2  grams  yolk  (%  tea- 
spoon). 

A  2-per-cent.  fat  mixture  is  furnished  approxi- 
mately by  10  c.c.  of  cream,  or  4  grams  of  yolk  (1 
teaspoon). 

A  3-per-cent.  fat  mixture  is  furnished  approxi- 
mately by  15  c.c.  of  cream,  or  6  grams  yolk  (ll^ 
teaspoons). 

A  4-per-cent.  fat  mixture  is  furnished  approxi- 
mately by  20  c.c.  of  cream,  or  8  grams  yolk  (2 
teaspoons). 

The  primary  caloric  value  of  the  fats  of  both 


164         Fasting  and  Undernutrition  in 

fat-compounds  naturally  is  the  same,  but  the  ab- 
sorbability of  the  yolk-fat  as  shown  by  me  in  the 
previous  chapter  (*^The  Yolk  Cure  in  the  Treat- 
ment of  the  Underfed")  is  greater  than  that  of 
any  other  animal  fat.  As  a  matter  of  fact,  there- 
for, yolk-fat  generates  more  calories  and  is  of 
higher  nutritive  value  than  milk-fat.  Thus,  it 
evinces  that  the  figures  heretofore  given,  can 
serve  for  general  orientation  only. 

I  do  not  offer  any  suggestions  as  to  the  further 
modification  of  cow's  milk  besides  that  on  which 
I  have  already  dwelt.  There  are  numerous  meth- 
ods in  vogue  and  every  practitioner  of  experience 
knows  how  to  obtain  a  certain  percentage  and 
quantity  of  proteids  and  carbohydrates.  Practi- 
cally speaking,  I  confine  myself  to  the  recommen- 
dation of  skimmed  milk*  and  the  addition  thereto 
of  physiologic  amounts  of  a  non-deleterious  native 
fat-compound.  It  is  the  office  of  the  clinician  to 
devise  any  further  modification  of  the  skimmed 
milk.f 

The  unaltered  native  yolk-fat  is  the  one  which 
I  have  made  use  of  in  my  experiments.  Good  re- 
sults can  only  be  obtained  by  employing  the  un- 

*  Of  course,  skimmed  milk  still  contains  about  0.2  per  cent.  fat. 
This  we  cannot  remove  without  rendering  the  milk  unfit  for  the 
use  of  the  infant. 

t  Whey  and  junket  from  modified  skimmed  milk  and  propor- 
tional amounts  of  egg  yolk  suitable  for  marasmic  infants  may 
be  readily  prepared.  The  milk-curdling  ferment,  however,  should 
be  in  a  menstruum  free  from  alcohol  and  free  acid,  which  latter 
are  apt  to  increase  the  underlying  gastro-intestinal  disturbance. 


The  Treatment  of  Diabetes  165 

manipulated  raw  yolk.*  The  less  the  yolk  is  agi- 
tated the  easier  it  is  of  digestion,  and  the  more  it 
retains  its  fermentative  and  stimulating  proper- 
ties. It  is  to  be  added  to  the  already  prepared 
skim-milk  modification  after  the  latter  has  been 
warmed  to  about  105  deg.  F. 

The  electrical  conductivity  of  skimmed  milk 
plus  physiological  amounts  of  yolk-fat  is  prob- 
ably somewhat  greater  than  that  of  native  milk. 
Skimmed  milk  exhibits  a  greater  conductivity  than 
the  native  product,  the  former  48.57,  the  latter 
47.62.  This  is  caused  by  the  interference  of  the 
fat  globules  with  the  movement  of  the  ions.  The 
fat-globules  of  native  milk  outnumber  those  which 
are  due  to  yolk-fat  when  added  in  physiological 
amounts  to  skimmed  milk. 

Let  us  review  the  data  which  we  may  glean 
from  this  chapter. 

First. — The  overwhelming  majority  of  cases  of 
infantile  marasmus  occur  in  artificially  nourished 
children. 

Second. — The  gastro-intestinal  disturbances 
underlying  infantile  atrophy  are  very  often  due 
to  the  character  of  the  food  and  not  infrequently 
to  its  fatty  contents. 

Third. — ^While  the  quantity  of  fat  aliment  has 
found  frequent  practical  consideration,  the  chemi- 
cal character  of  the  fatty  substances  entering  into 

*  Cooking  or  sterilization  changes  the  physical  conditions  of 
all  animal  fats,  especially  of  that  of  the  milk  and  yolk. 


166        Fasting  and  Undernutrition  in 

the  baby's  nutriment  have  hardly  ever  been  in- 
quired into  by  the  clinician. 

Fourth. — The  composition  of  the  fat  of  cow's 

ilk  is  greatly  at  variance  with  that  of  the  fat 
of  human  milk,  differing  especially  in  its  far 
greater  contents  of  volatile  fatty  acids  among 
w^hich  butyric  acid  is  the  most  important. 

Fifth. — Butyric  acid  is  the  mother  substance  of 
the  acetone  bodies  to  the  presence  of  which  a 
number  of  disorders,  to  which  the  infant  is  prone, 
have  been  ascribed  by  various  observers. 

Sixth. — Butyric,  caproic,  caprylic  and  capric 
acids  are  contained  in  the  fat  of  cow's  milk  in 
from  six  to  eight  times  the  amount  in  which  they 
are  present  in  that  of  human  milk,  and  the  large 
quantity  of  their  respective  ketones  that  is 
yielded  in  the  alimentary  tract  must  be  a  source 
of  irritation  and  intoxication. 

Seventh. — The  infantile  organism  cannot  cope 
successfully  with  the  fat  of  cow's  milk  even  in  a 
mere  physical  sense.  This  is  evidenced  by  the 
decidedly  smaller  absorption  of  the  fat-compound 
derived  from  cow's  milk  than  from  human  milk. 
The  occurrence  in  the  feces  of  absolutely  and 
relatively  larger  amounts  of  fat  of  cow's  milk 
is  prima  facie  evidence  of  its  more  incomplete 
utilization  by  the  youthful  organism. 

Eighth. — As  the  physical  and  chemical  proper- 
ties of  the  milk-fat  are  dependent  upon  the  ab- 
solute and  relative  amount  of  lower  and  higher 
and  uncombined  fatty  acids,  it  is  evident  that  the 


The  Treatment  of  Diabetes  167 

vast  discrepancy  existing  between  the  constitu- 
tion of  cow's  milk-fat  and  mother's  milk-fat  can- 
not be  overcome  by  any  possible  modification  of 
the  former. 

Ninth. — Apart  from  the  butyric  acid  origin  of 
the  acetone  bodies  we  find  that  the  volatile  fatty 
acids  as  furnished  by  the  fat  of  cow's  milk  and 
their  respective  ketones  are  decided  irritants  of 
the  delicate  intestinal  mucosa  of  the  infant,  and 
may  also  play  the  part  of  intoxicants.  The  in- 
gestion of  these  acids  is,  therefore,  the  primary 
cause  of  many  instances  of  gastro-intestinal  irri- 
tation and  disease  followed  by  undernutrition, 
bodily  retrogression  and  athrepsia  infantum. 

Tenth, — Alteration  in  the  fat  supply  as  exer- 
cised today  is  almost  mthout  exception  a  quan- 
titative one,  consisting  of  reduction,  suspension 
and  even  increased  supply  of  fat-aliment. 

Eleventh. — Withdrawal  of  milk-fat  in  hand-fed 
infants  frequently  results  in  cessation  of  the  local 
and  systemic  disturbance.  It  is,  however,  obvious 
that  the  infant  cannot  exist  for  any  length  of  time 
without  fatty  ingesta  of  some  kind.  Further- 
more, the  incipient  marasmic  condition  cannot  be 
relieved  unless  a  sufficient  amount  of  assimilable 
fats  yielding  but  insignificant  amounts  of  volatile 
fatty  acids  is  added  to  the  nutriment. 

Twelfth, — Yolk-fat  seems  to  be  the  ideal  fat  for 
infants  suffering  from  chronic  gastro-intestinal 
disturbance  together  with  latent  or  even  pro- 
nounced athrepsia  infantum. 


168         Fasting  and  Undernutrition 

Thirteenth. — Yolks  should  not  find  employment 
in  the  newborn  nor  in  the  infant  which  thrives 
on  the  physiologic  nutriment  or  on  a  modification 
of  cow's  milk.  Yolks  should  be  used  only  in  those 
pathologic  conditions  w^hich  may  lead  to  athrepsia 
infantum  and  in  those  which  are  due  to  or  aggra- 
vated by  the  fat  constituents  of  the  nourishment. 

Fourteenth. — There  are  two  essentials  which 
must  be  followed  in  order  to  obtain  good  results 
from  the  ingestion  of  yolks,  viz.,  the  yolk-fat 
must  completely  replace  the  milk-fat,  and  the 
amount  of  yolk-fat,  without  being  in  excess,  must 
be  adequate,  that  is,  it  must  conform  to  the  caloric 
and  nutritive  demands  of  the  organism. 

Fifteenth.  —  The  electrical  conductivity  of 
skimmed  milk  plus  physiological  amounts  of 
yolk-fat  is  probably  somewhat  greater  than  that 
of  native  milk. 

Refeeences 

11  Archiv.  f.  Kinderheilkunde,  Vol.  II,  1881. 

12  Zeitschr.  f .  klin.  Medizin.,  Vol.  XLII. 


ASSAY  OF   THE   URINE 


ASSAY  OF   THE  URINE 

The  examination  of  the  urine,  as  hereafter  out- 
lined, is  limited  to  the  substances  which  are 
found,  or  are  apt  to  be  found,  in  the  renal  secre- 
tion of  the  diabetic.  Only  the  ordinary  and  most 
frequent  pathological  substances,  and  such  sim- 
ple tests  which  can  be  performed  without  especial 
technical  skill  and  complicated,  costly  apparatus 
are  mentioned.  Qualitative  and  quantitative 
tests  are  given.  In  general,  qualitative  testing 
suffices  in  cases  when  the  patient  whose  urine  has 
been  rendered  free  from  pathologic  bodies  con- 
tinues to  remain  under  the  same  dietary  in- 
fluences; quantitative  testing,  on  the  other  hand, 
becomes  imperative  when  the  pathologic  material 
persists  in  the  urine  or  when  the  slightest  dietary 
change  has  taken  place.  Qualitative  tests,  of 
course,  demand  the  least  skill  and  time.  Every- 
body, however,  who  devotes  sufficient  attention 
to  it,  may  become  well  versed  in  the  quantitative 
testing  for  the  urinary  substances  that  are  of 
common  occurrence  in  diabetes. 

A.    Detection 

The  delicacy  of  a  test  for  glucose  is  dependent 
upon  the  character  of  the  latter 's  solution,  hence, 

171 


172        Fasting  and  Undernutrition  in 

a  test  for  dextrose,  in  point  of  sensitiveness,  re- 
sponds differently  if  applied  to  a  watery  solution 
than  if  nsed  with  the  nrinary  fluid.  Furthermore, 
the  delicacy  of  a  glucose  test  is  not  the  same  in 
all  urines,  it  being  dependent  on  quality  and 
quantity  of  the  other  urinary  constituents.  Sen- 
sitiveness of  a  method  for  the  detection  of  glu- 
cose in  the  urine  is  by  no  means  identical  with  its 
accuracy  and  reliability.  Thus,  Trommer's  test, 
for  instance,  is  an  exceedingly  delicate  one,  if 
skilfully  applied  to  certain  urines;  in  the  great 
majority  of  instances,  however,  its  trustworthi- 
ness cannot  be  relied  upon  for  amounts  of  dex- 
trose less  than  0.5  per  cent.  The  same  may  be 
said  of  the  other  testing  methods  in  general  usage. 
Bottger's  or  Johnson's  picric  acid  or  the  fermen- 
tation tests  are  equally  delicate  under  favorable 
conditions,  but,  according  to  my  experience,  their 
employment  should  be  restricted  to  urines  con- 
taining 0.5  per  cent,  and  more  of  grape-sugar. 

By  the  application  of  the  tests  most  generally 
used,  pathologic  quantities  of  urinary  glucose 
may  be  overlooked  altogether,  or  grape-sugar 
may  be  confounded  with  a  number  of  other  uri- 
nary constituents.  Especially  is  this  the  case 
where  the  other  concomitant  manifestations  are 
equally  ill-pronounced.  I  have  prepared  the  fol- 
lowing table  to  show  the  limit  of  sensitiveness 
and  that  of  reliability  of  the  different  tests. 


The  Treatment  of  Diabetes 


173 


Tests  for  Dextrose  in  the  Urine. 


Bismuth  Tests, 

Bottger's 

Nylander's 

Briicke's 

Maschke'3 

Copper  Tests. 

Trommer's 

Salkowski's 

Seegen's  (filtration  of  urine  through 
animal  charcoal) 

Fehling's 

Worm-Mueller's , 

Haines' 

Elliott's 

Pavy's 

Phenylhydrazin  t'^st 

Moore-Heller's 

Penzoldt-Rubner's  (ammonia-lead  ace 

tate) 

Methylene-blue  test 

Picric-acid  test 

Sodium  sulpho-indigotin 

Hoppe-Seyler's   (Nitrophenylpropiolic 

acid) 

Penzoldt's    (Paradiazobenzolsulphonic 

acid) 

Furf urol  tests 

Horsley-Pratesi's  (caustic  potash,  po- 
tassic  silicate,  potassic  bichromate) 

Fermentation  test 

Polarization 


Limit  of 

Limit  of 

Sensitiveness. 

Reliability. 

Percentage. 

Percentage. 

0.1 

0.5 

0.1 

0.3 

0.2 

0.4 

0.2 

0.4 

0.1 

0.5 

0.5 

0.5 

0.01 

0.05 

0.3 

0.3 

0.25 

0.3 

0.2 

0.3 

0.2 

0.3 

0.2 

0.3 

0.03 

0.05 

0.5 

0.75 

0.1 

0.2 

0.04 

0.3 

0.1 

0.5 

0.1 

0.5 

0.5 

0.75 

0.1 

0.3 

0.02 

? 

0.4 

0.75 

0.1 

0.5 

0.01 

1.0 

with  best 

and  over  by 

instrument. 

instruments  in 

general  use. 

Nylander's  Test. — ^Almen's  solution  is  the  rea- 
gent employed  in  this  method.  It  is  prepared  as 
follows :  Potassium  and  sodium  tartrate,  4  grams, 
and  basic  bismuth  nitrate,  2  grams,  are,  under 
heat,  dissolved  in  100  grams  of  an  8  per  cent, 
solution  of  sodium  hydrate.  When  cooled  the 
yellow  bismuth  oxid  is  filtered  off  and  the  solu- 


174         Fasting  and  Undernutpjtion  ik 

tion,  which  does  not  deteriorate  for  a  long  time, 
is  kept  in  a  dark  bottle.  One  part  of  the  reagent 
is  added  to  ten  parts  of  the  suspected  urine. 
On  boiling  for  from  two  to  five  minutes  the  white 
precipitate  which  is  produced  by  the  addition  of 
the  test  solution  to  the  urine,  gradually  assumes  a 
more  pronounced  discoloration,  turning  finally 
black  in  the  presence  of  dextrose.  A  very  small 
percentage  of  sugar  produces  a  brown  hue  of 
the  precipitate;  a  dirty  yellow  or  a  grayish  dis- 
coloration is  of  no  significance  as  to  the  presence 
of  dextrose.  A  secondary  blackening  of  the  pre- 
cipitate, which  may  take  place  when  the  urine 
mixture  in  the  test  tube  is  cooled  off,  does  not 
evince  the  occurrence  of  abnormal  quantities  of 
grape  sugar.  Uric  acid  and  kreatinin  do  not  re- 
duce the  bismuth  salt.  Pure  peptone  does  also 
not  influence  the  reaction.  The  test  boils  over 
easily;  this  may  be  prevented  by  placing  the  test 
tube  into  a  water-bath.* 

Disturhing  factors  and  sources  of  error. — Pig- 
mentary bodies,  principally  uroerythrin,  hemato- 
porphyrin,  indoxyl-glycuronic  acid  and  other 
glycuronic  acid  compounds,  ammonium  carbonate 
in  decomposing  urines,  hydrogen  sulphid,  mucin, 
albumin  and  other  urinary  constituents  into 
whose  composition  sulphur  enters.     If  the  re- 

*  The  reduction  or  pseudo-reduction  of  the  bismuth  salt  may 
he  frequently  due  to  substances  other  than  dextrose.  The  cMef 
value  of  this  test,  however,  lies  in  its  negative  result,  for  the 
non-reduction  of  the  hismuth  positivelif  excludes  the  presence  of 
glucose  in  ahnormal  quantities. 


The  Treatment  or  Diabetes  175 

agent  be  added  to  a  0.6  per  cent,  albumin  solution 
a  red  precipitate  will  be  produced;  in  urine  con- 
taining 1  to  2  per  cent,  of  albumin  the  ensuing 
precipitate  is  black,  and  in  appearance  easily 
mistaken  for  the  reduced  bismuth  salt.  The  re- 
action is  still  a  fair  one  if  0.2  per  cent,  albumin 
occur  together  with  0.1  per  cent,  sugar;  it  is  but 
faint  if  0.35  per  cent,  albumin  occurs  simultane- 
ously with  the  same  quantity  of  sugar;  if  the 
reaction  will  not  take  place,  0.45  per  cent,  albu- 
min is  contained  in  a  0.1  per  cent,  sugar  solution. 
Saccharin  is  among  the  substances  preventing 
the  reduction.  Eeduction  of  bismuth  oxid  has 
been  noticed  after  the  administration  of  a  num- 
ber of  drugs,  as  antipyrin,  acetanilid,  arsenic, 
salicylic  acid  or  salicylates,  quinin,  sulphur,  mer- 
curials, salts  of  iodin,  turpentin,  kairin,  rheum, 
senna,  santonin,  tannic  acid,  chloral  hydrate,  tinc- 
ture of  eucalyptus,  salol,  benzol,  sulfonal,  trional, 
sodium  benzoate,  large  doses  of  creosote  (Stern), 
podophyllotoxin  (Stern).  There  is  little  doubt, 
in  my  opinion,  that  the  administration  of  some  of 
these  drugs  is  followed  by  an  increased  output  of 
urinary  pigmentary  substances  to  which  the  re- 
ducing qualities  have  to  be  ascribed.  In  other 
instances,  as  with  rheum  and  senna,  the  reducing 
power  seems  to  lodge  with  the  newly  ingested 
chrysophanic  acid  (C15H10O4). 

Prevention, — Separation  of  the  coloring  mat- 
ters, removal  of  the  hydrogen  sulphid  by  agita- 
tion  with   lead   oxid,   elimination   of   proteids. 


176         Fasting  and  Undernutrition  in 

Specimen  of  urine  should  be  voided  in  a  period 
during  which  no  medicinal  agents  were  admin- 
istered. 

For  all  practical  purposes  Nylander's  method 
for  the  detection  of  sugar  in  the  urine  is  the  most 
simple  and  at  the  same  time  the  most  reliable  test 
devised  for  the  purpose.  Nevertheless,  the  great 
value  of  this  test  is  virtually  but  an  indirect  one — 
the  non-reduction  of  the  bismuth  salt  is  positive 
evidence  of  the  absence  of  pathologic  amounts  of 
grape-sugar, 

B.    Determination 

Fermentation  Test. — This  is  one  of  the  most 
reliable  tests  for  the  detection  of  urinary  glu- 
cose provided  the  latter  occurs  in  quantities 
above  0.5  per  cent.  Certain  vegetable  organisms 
by  their  vitality  call  forth  disintegration  of 
grape-sugar.  The  products  of  decomposition 
vary  according  to  the  species  of  organism  pres- 
ent. Beer-yeast  breaks  up  the  sugar  molecule 
into  carbon  dioxid  and  alcohol  in  neutral  or 
faintly  acid  solutions.  In  the  main  the  fermen- 
tation occurs  thus :  C6Hi206==2C2H60-f  2CO2. 
Lactic  acid  yeast  converts  glucose  into  lactic 
acid;  lactic  fermentation  may  take  place  in 
diabetic  urine  if  ammonium  carbonate  has  re- 
placed the  latter 's  carbamid  (urea).  Butyric  acid 
yeast  converts  sugar  into  butyric  acid.  Mycoder- 
ma  aceti  causes  conversion  of  dextrose  into  an 
acid  identical  with  glucinic  acid.    Kefyr  produces 


The  Treatment  of  Diabetes  177 

fermentative  changes  of  glucose.  A  number  of 
other  specific  microorganisms  cause  specific  fer- 
mentations. The  fermentation  test  for  urinary 
glucose  is  made  with  fresh  beer-yeast,  or  with 
dried  German  yeast,  a  combination  of  beer-yeast 
and  dry  starch,  at  a  constant  temperature  of  33 
to  35  C.  For  qualitative  testing  the  fermenta- 
tion tubes  devised  by  Fritz  Moritz*  suffice.  The 
determination  of  dextrose  by  collecting  and  meas- 
uring the  carbon  dioxid  evolved  during  the  proc- 
ess of  fermentation  may  be  approximately  done 
with  Einhorn's  or  Fiebig's  saccharometers.  The 
method  of  determining  the  amount  of  glucose  by 
the  evolved  carbon  dioxid  must  always  remain 
inexact,  as  the  yeast  per  se,  no  matter  what  pre- 
cautions are  taken,  furnishes  small  amounts  of 
alcohol  and  carbonic  acid  gas,  Einhorn^s  appa- 
ratus presents  a  further  disadvantage  in  its  open 
bulb,  which  permits  the  escape  of  considerable 
quantities  of  carbon  dioxid.  The  detection  and 
determination  of  glucose  by  Eobert's  method — 
by  ascertaining  the  density  of  urine  before  and 
after  fermentation  and  by  calculating  the  urine's 
contents  of  sugar  by  the  loss  of  specific  gravity 
during  fermentation — is  by  far  the  most  prac- 
tical and  trustworthy  means  in  the  hands  of  the 
general  practitioner.  The  author  has  devised  an 
apparatus  for  the  practical  and  convenient  appli- 
cation of  this  method.  This  apparatus,  the  gln- 
cosometer,  may,  moreover,  be  utilized  for  the 

*  Mttnchener  Med.  Wochenschrift,  1891,  Nos.  1  and  2. 


178         Fasting  and  Undernutrition  in 

detection  of  glucose  only,  by  interrupting  the 
fermentation  after  an  hour  or  so  and  by  ascer- 
taining any  decline  in  the  specific  gravity  of  the 
dextrose  solution. 


Stern's  Glucosometer  (One-half  the  Apparatus) 

Disturbing  factors  and  sources  of  error. — Mal- 
tose, fructose,  and  similar  carbohydrates  ferment 
with  commercial  yeast.  The  process,  however, 
is  a  much  slower  one.  It  happens  occasionally 
that  a  urine  containing  glucose  is  not  ferment- 
able. This  is  due  to  anti-fermentative  agents,  as 
salicylic  acid,  salol,  arbutin,  extractum  myrtilli, 
etc.,  after  their  internal  administration. 

Directions  for  Using  Stern's  Glucosometer, — 


The  Treatment  of  Diabetes  179 

The  urine  is  placed  into  the  fermentation  tube 
exactly  to  the  mark  50  c.c.  Then  the  desired 
urinometer  (two  such  instruments  accompany  the 
apparatus,  one  for  the  specific  gravity  from  990 
to  1030,  the  other  from  1030  to  1070)  is  inserted 
and  the  aluminum  cap  is  placed  in  its  proper  po- 
sition. Following  this  the  specific  gravity  on  the 
flat  top  of  the  cap  is  read  off  and  written  down. 
(The  reading  of  the  specific  gravity  on  the  flat  top 
outside  the  tube  fixes  the  meniscus  and  permits 
exactness;  half  a  degree  of  the  specific  gravity 
can  be  readily  estimated.)  After  this  cap  and 
urinometer  are  removed  and  three  or  four  grams, 
that  is  one-quarter  or  one-third  of  a  cake  of 
Fleischmann's  yeast  is  added.  Again  the  same 
hydrometer  is  inserted  and  the  tube  closed  by 
means  of  the  cap.  (The  hydrometer  need  not  be 
placed  into  the  tube  at  once;  this  can  be  done 
after  fermentation  is  completed.  However,  it  is 
better  to  place  it  in  position  when  starting,  as  it 
will  then  indicate,  step  by  step,  the  progress  of 
the  fermentation.)  The  yeast  cell  will  become 
active  at  a  temperature  of  from  27  to  28  deg.  C, 
that  is  from  80  to  82  deg.  F.  The  apparatus 
should,  therefore,  be  placed  in  a  room  in  which 
there  is  a  constant  temperature  of  that  degree. 
Fermentation  in  this  moderate  temperature  will 
be  completed  in  from  twelve  to  fifteen  hours. 
The  CO2  which  is  evolved  during  the  process 
will  escape  through  the  perforations  in  the  alu- 
minum cap.    After  completion  of  the  fermenta- 


180         Fasting  and  Undernutrition  in 

tion  the  cap  should  be  lifted  for  a  short  time, 
the  urine  stirred  or  whipped,  or  the  tube  shaken 
to  effect  a  more  complete  elimination  of  the 
CO2.  (Care  must  be  taken  that  not  a  drop  of 
the  urine  be  spilled.)  After  this  the  cap  should 
be  again  placed  in  position,  the  yeast  particles 
be  allowed  to  settle  (which  takes  place  rapidly), 
and  the  specific  gravity  be  .read  off  at  the  flat 
top  of  the  cap.  The  difference  between  the  spe- 
cific gravity  before  and  after  fermentation  is 
then  compared  and  the  degrees  of  density  lost 
during  this  process  ascertained.  Each  degree 
of  specific  gravity  lost  corresponds  to  0.2288 
(approximately  0.23)  gram  of  glucose  in  every 
100  c.c.  of  urine  (one  grain  to  the  ounce  of 
urine).  Thus,  if  the  density  of  the  unfermented 
urine  was  1036  and  of  the  fermented  urine  1020, 
the  sixteen  lost  degrees  must  be  multiplied  by 
0.2288.  Therefor,  3.6608  grams  of  glucose  are 
contained  in  100  c.c.  of  the  urine. 

The  amount  of  glucose  voided  during  the  twen- 
ty-four hours  may  be  easily  calculated  if  the 
quantity  of  urine  passed  in  that  time  be  known 
and  if  the  examined  portion  of  the  same  was 
a  specimen  of  the  diurnal  mixture.  If  it  be 
desired  to  ascertain  the  quantity  of  glucose  in 
grains  to  the  fluid  ounce  of  urine,  no  calculation 
is  necessary,  as  each  degree  of  density  corre- 
sponds exactly  to  one  grain  of  glucose  per  fluid 
ounce.  For  instance,  if  the  specific  gravity  of 
the  urine  be  1036  before  fermentation  and  1020 


The  Treatment  or  Diabetes  181 

after  this  process,  sixteen  grains  of  glucose  were 
contained  in  each  ounce  of  the  tested  urine. 

To  effect  complete  fermentation  in  six  hours 
the  tubes  may  be  had  in  a  form  that  they  can 
be  inserted  into  a  sand-bath  or  used  in  the  incu- 
bator. The  best  protectors  and,  incidentally, 
the  best  promoters  of  the  yeast  cell's  activity, 
are  the  sand-bath  or  the  incubator  with  a  tem- 
perature at  or  near  33.5  deg.  C.  (92  deg.  F.). 

Fehling's  Test. — In  case  the  urine  contains 
appreciable  amounts  of  serum  albumin  and 
globulin  they  should  be  removed  by  acidifying, 
boiling,  and  filtering  before  it  is  subjected  to 
Fehling's  test.  However,  the  serines  only  give 
rise  to  a  partial  reduction  of  the  test  fluid,  and 
it  is  hardly  necessary  to  remove  them  in  the  or- 
dinary examination. 

It  is  generally  recommended  that  the  diabetic 
urine  be  diluted  ten  times  its  volume  with  water 
before  proceeding  with  the  test  proper.  This, 
however,  is  only  called  for  in  cases  when  the 
sugar  content  is  very  large.  For  clinical  pur- 
poses the  test  with  the  native  urine  will  ordi- 
narily give  quite  accurate  results. 

Preparation  of  Fehling's  solution. — Solution 
A. :  34.64  grams  sulphate  of  copper  is  dissolved 
in  500  c.c.  of  distilled  water. 

Solution  B :  180  grams  neutral  potassium  tar- 
trate and  70  grams  sodium  hydrate  are  dis- 
solved in  300  c.c.  of  water.  When  cold,  200  c.c. 
of  water  are  added. 


182 


Fasting  and  Undernutrition  in 


These  solutions  should  be  kept  in  separate 
bottles  and  mixed  as  required  in  equal  volumes 
of  5  c.c.  each.  The  copper  in  10  c.c.  of  Fehling's 
solution  is  reduced  by  exactly  0.05  gram  glu- 
cose. 

Method. — Exactly  5  c.c.  of  each  solution  (A 
and  B)  is  measured  off  in  a  10  c.c.  cylinder 
graduate.  The  10  c.c.  are  placed  into  a  porce- 
lain evaporating  dish  which  stands  in  a  water- 
bath  or  on  an  asbestos  or  iron  screen.  Gas  or 
alcohol  is  used  for  boiling. 


Apparatus  foe  Steen's  Modification  of  Fehling's  Test 

A.  Cylinder  graduate 

B.  Evaporating  dish 

C.  Asbestos  or  iron  screen  (foil) 

D.  Gas  pipe 


The  Treatment  of  Diabetes  183 

Following  this  the  same  narrow  cylinder  grad- 
uate (wliich  is  divided  into  tenths  of  cubic  cen- 
timeters) is  thorouglily  cleaned  and  the  urine 
filled  exactly  to  the  10  c.c.  mark.  The  urine  is 
then  allowed  to  drop  slowly  into  the  boiling 
Fehling's  solution,  while  the  mixture  is  being 
constantly  stirred.  This  is  continued  until  the 
blue  or  purplish  color  has  entirely  disappeared 
and  until  the  mixture  is  uniformly  yellowish  or 
reddish  and  a  slight  deposit  of  either  yellow  or 
red  has  formed. 

(The  end  reaction  is  the  most  difficult  factor 
connected  with  the  test.  The  assay  should  be 
conducted  in  daylight.  One  soon  becomes  an 
expert  in  testing  with  Fehling's  solution  if 
proper  care  is  exercised  in  adding  no  more  nor 
less  urine  to  the  test-fluid  than  is  necessary  to 
produce  a  uniform  reduction.  If  the  porcelain 
dish  is  left  standing  after  the  copper  is  reduced, 
the  mixture  soon  turns  blue  again.  This  is  due 
to  the  hydration  of  the  copper  and  has  nothing 
'to  do  with  an  insufficient  reduction.) 

In  case  the  solution  is  not  reduced  by  10  c.c. 
of  the  urine,  an  additional  10  c.c.  urine  are 
poured  into  the  cylinder  graduate,  and  this  is 
repeated  until  30  or  40  c.c.  urine  are  added  to 
the  boiling  Fehling's  solution  in  the  porcelain 
dish  (a  dish  of  70  c.c.  capacity  is  the  best  for 
ordinary  use). 

Now  the  amount  of  urine  that  was  necessary 
to  effect  the  complete  reduction  of  the  solution 


184 


Fasting  and  Undernutrition  in 


is  ascertained,  and  the  amount  of  urinary  sugar 
calculated. 

Example. — If  6  c.c.  of  undiluted  urine  have 
been  required  to  reduce  all  the  copper  in  the 
10  c.c.  Fehling's  solution,  then  the  6  c.c.  urine 
contain  0.05  gram  glucose. 

Expressed  in  per  cent.,  this  is 

6:100::0.05:X  =  0.83 

The  twenty-four  hours'  output  of  sugar  is 
readily  calculated  by  multiplying  the  per  cent, 
figure  by  the  number  of  cubic  centimeters  of 
urine  voided  in  this  period.  If,  for  instance, 
2150  c.c.  of  urine  were  passed  by  the  same  pa- 
tient during  this  time,  then  0.83  X  2150  =  17.84 
grams  glucose  were  excreted  by  him. 

The  accompanying  tables  will  be  found  very 
useful  in  the  clinical  laboratory: 


TABLE  SHOWING  THE  EQUIVALENCE  OF  GRAMS  PEE 
CENT.  OF  SUGAR  IN  GRAINS  PER  OUNCE  OF  URINE. 


Grams 

Grains 

Grams 

Grains 

per  cent. 

per  ounce. 

per  cent. 

per  ounce 

0.05 

=z 

0.218 

0.8 

= 

3.498 

0.1 

-~~* 

0.437 

0.85 

zrr 

3.717 

0.15 

rzz 

0.656 

0.9 

= 

3.937 

0.2 

= 

0.8746 

0.95 

:::zi 

4.156 

0.25 

— 

1.093 

1.0 

z=. 

4.375 

0.3 

= 

1.312 

1.1 

=z 

4.8 

0.35 

z=: 

1.530 

1.2 

r= 

5.25 

0.4 

= 

1.749 

1.3 

"TT 

5.70 

0.45 

r=. 

1.968 

1.4 

= 

6.125 

0.5 

z=. 

2.186 

1.5 

m 

6.561 

0.55 

z=. 

2.406 

1.6 

zzz 

7.00 

0.6 

=. 

2.624 

1.7 

z= 

7.437 

0.65 

=: 

2.843 

1.8 

= 

7.874 

0.7 

"^^^z 

3.062 

1.9 

zzz 

8.311 

0.75 

rr: 

3.280 

2 

z=, 

8.750 

The  Treatment  of  Diabetes 


185 


Grams 

Grains 

Grams 

Grains 

per  cent. 

per  ounce. 

per  cent. 

per  ounce 

2.5 

= 

10.936 

6.5 

=         28.436 

3 

— 

13.125 

7 

=         30.622 

3.5 

= 

15.311 

7.5 

=         32.808 

4 

— 

17.500 

8 

=:         34.994 

■     4.5 

= 

19.686 

8.5 

=         37.183 

5 

znz 

21.872 

9 

=         39.370 

5.5 

*""* 

24.058 

9.5 

=         41.558 

6 

— 

26.250 

10 

=         43.750 

6.25 

=: 

27.343 

TABLE  SHOWING  PER  CENT.  OF  SUGAR  PRESENT  IN 
THE  URINE,  WHEN  THE  FOLLOWING  AIMOUNTS  OF 
PURE  URINE  HAVE  BEEN  REQUIRED  TO  COM- 
PLETELY REDUCE  THE  COPPER  IN  10  c.c.  OF  STAND- 
ARD  FEHLING'S   SOLUTION. 


Grams 

Grams 

Amount  of 

of  Sugar 

Amount  of 

of  Sugar 

Urine  used. 

per  cent. 

L^rine  used. 

per  cent. 

0.1 

c.c. 



50 

2.25 

c.c. 



2.22 

0.2 

a 

rr: 

25 

2.3 

(( 



2.17 

0.25 

a 

= 

20 

2.4 

(( 

= 

2.08 

0.3 

a 

= 

16.6 

2.5 

(( 

zz= 

2 

0.4 

a 

— 

12.5 

2.6 

(( 

= 

1.92 

0.5 

ti 

= 

10 

2.7 

(C 

=z 

1.85 

0.6 

a 

= 

8.33 

2.75 

a 

~~~ 

1.81 

0.7 

a 

= 

7.14 

2.8 

i( 

z=. 

1.78 

0.75 

(( 

~~~ 

6.6 

2.9 

a 

= 

1.72 

0.8 

a 

r=: 

6.25 

3 

a 

■=. 

1.66 

0.9 

li 

r= 

5.55 

3.25 

li 

= 

1.53 

1 

(I 

— 

5 

3.5 

11 

m 

1.42 

1.1 

i< 

~~" 

4.54 

3.6 

li 

= 

1.38 

1.2 

(( 

—^ 

4.17 

3.7 

(I 

z=z 

1.35 

1.25 

i( 

■=. 

4 

3.75 

li 

r= 

1.33 

1.3 

a 

= 

3.8 

3.9 

11 

r:^ 

1.28 

1.4 

a 

Z=l 

3.57 

4 

11 

■==. 

1.25 

1.5 

a 

= 

3.33 

4.25 

a 

=: 

1.17 

1.6 

li 

z=. 

3.12 

4.5 

ii 

— 

1.11 

1.7 

a 

■=. 

2.94 

4.6 

11 

■=. 

1.08 

1.75 

ce 

— 

2.85 

4.7 

ii 

= 

1.06 

1.8 

(( 

= 

2.77 

4.75 

11 

■=z 

1.05 

1.9 

(C 

z=r 

2.63 

4.9 

11 

= 

1.02 

2 

« 

r= 

2.5 

5 

li 

nr 

1 

2.1 

(( 

= 

2.39 

5.25 

li 

= 

0.95 

2.2 

(( 

'=. 

2.27 

5.5 

li 

rz: 

0.9 

186        Pasting  and  Undernutiiition  m 


Grams 

Grams 

Amount  of 

of  Sugar 

Amount  of 

of  Sugar 

Urine  used. 

per  cent. 

Urine  used. 

per  cent. 

5.75 

c.c. 

— 

0.87 

10.5 

c.c. 

= 

0.47 

6 

— : 

0.83 

11 

(< 



0.45 

6.25 

= 

0.8 

11.5 

(C 

z=: 

0.43 

6.5 

rrr 

0.76 

12 

il 

— 

0.416 

6.75 

— 

0.73 

12.5 

a 

irr: 

0.4 

7 

=z 

0.71 

13 

li 

= 

0.38 

7.25 

= 

0.68 

14 

(( 

z=: 

0.36 

7.5 

z= 

0.66 

15 

a 

:== 

0.33 

7.75 

■ — 

0.64 

16 

i< 

— 

0.31 

8 

— 

0.625 

17 

(( 

= 

0.29 

8.25 

— 

0.606 

18 

(t 

— 

0.2T 

8.5 

=: 

0.58 

19 

(C 

= 

0.26 

8.75 

— 

0.57 

20 

(( 

z=z 

0.25 

9 

= 

0.55 

25 

(I 

= 

0.2 

9.25 

— 

0.54 

30 

(( 

= 

0.16 

9.5 

= 

0.52 

35 

« 



0.14 

9.75 

— ■ 

0.51 

40 

« 

:=:: 

0.125 

10 

0.5 

Ace: 

50 
rONE 

(( 

0.10 

Detection 

(a)  Sodium  Nitroprusside  Test. — Eeagent: 
Solution  of  0.1  gram  sodium  nitroprusside  in 
15  c.c.  distilled  water. 

Method, — To  2  c.c.  of  the  solution  contained 
in  a  test  tube  twice  tlie  volume  of  freshly  voided 
urine  is  added.  After  the  addition  of  some 
potassium  or  sodium  hydrate  a  ruby  red  color 
is  assumed  by  the  mixture  in  case  acetone  be 
present.  On  the  addition  of  a  few  drops  of 
acetic  acid  this  color  disappears  at  once,  if  ace- 
tone is  not  contained  in  the  urine.  If,  however, 
acetone  be  present,  the  addition  of  acetic  acid 
intensifies  the  ruby  tint. 

Sources   of  error, — Kreatinin,   aldehydes   and 


The  Treatment  of  Diabetes  187 

chloroform  may  give  similar  reactions,  but  the 
red  color  quickly  turns  to  yellow  on  the  addi- 
tion of  acetic  acid. 

(b)  Sodium  Nitroprusside  Test  (Niece's  Im- 
provement).— Reagent:  Ammonium  nitrate  (crys- 
tals), 30  grams;  sodium  nitroprusside  (crystals), 
2  grams;  distilled  water,  enough  to  make  80  c.c. 
Mix  in  the  order  given,  dissolve  and  keep  in  a 
well-corked  bottle  protected  from  sunlight. 

Method. — ^With  5  c.c.  of  freshly  voided  urine 
contained  in  a  test  tube  0.5  to  1  c.c.  of  the  re- 
agent is  well  mixed.  Then  3  c.c.  of  a  10-per- 
cent, solution  of  ammonium  hydroxid  are  care- 
fully added  by  contact.  If  acetone  be  present 
there  is  innnediately  produced  at  the  zone  of 
contact  a  purple  or  *' Burgundy  red"  coloration. 
On  standing  the  color  diffuses  mostly  upward 
into  the  ammonium  layer;  its  depth  of  color  is 
in  proportion  to  the  amount  of  acetone  present. 

When  the  amount  of  acetone  be  small  the 
color  is  in  the  beginning  a  deep  rose  pink,  but  it 
soon  changes  to  purple  or  violet.  The  mixture 
should  be  allowed  to  stand  for  from  two  to  five 
minutes  before  examination.  When  the  two  so- 
lutions blend  there  ensues  coloration  of  the 
entire  fluid.  The  color  deepens  gradually.  After 
another  five  or  ten  minutes  the  coloration  has 
reached  its  greatest  degree  of  intensity.  The 
color  slowly  fades  away  after  fifteen  or  twenty 
minutes,  so  that  within  one  hour  it  has  most 
always  entirely  disappeared. 


188  FASTIis^G   AND   UNDERNUTRITION    IN 

The  reagent  keeps  indefinitely,  and  the  usual 
sources  of  error  when  employing  the  ordinary 
sodium  nitroprusside  test  do  not  obtain.  The 
action  of  the  ammonium  salt  in  the  test  is  that 
of  a  stabilizer  and  catalyzer;  that  is,  it  prevents 
decomposition  of  the  nitroprusside  while  in  so- 
lution with  water,  assists  in  avoiding  false  side- 
reactions,  and  enhances  the  sensitiveness  of  the 
reagent. 

(c)  Lieben's  Test. — Eeagents:  Solution  of 
iodin  in  potassium  iodid  and  solution  of  potas- 
sium hydrate. 

Method. — To  the  urine  (a  distillate,  if  possi- 
ble) in  the  test  tube  some  potassium  hydrate 
solution  is  added.  To  this  is  added  some  drops 
of  a  strong  aqueous  solution  of  iodin  in  potas- 
sium iodid.  If  acetone  be  present,  crystals  of 
iodoform  will  separate  which  appear  under  the 
microscope  as  six-sided  plates  or  stars.  This  re- 
action is  neither  as  sensitive  nor 'as  reliable  as 
Niece's  modification  of  the  sodium  nitroprusside 
test.  The  scarcity  at  this  time  (during  the  Euro- 
pean war)  of  this  chemical,  however,  compels 
one  to  resort  to  inferior  and  more  complicated 
methods. 

DiACETic  Acid 

(Aceto-acetic  acid) 
Detection 

Ferric  Chlorid  Test  (Gerhardt). — To  5  c.c. 
of  recently  voided  urine  contained  in  a  test  tube 


The  Treatment  of  Diabetes  189 

a  strong  solution  i)f  ferric  chlorid  is  added  drop 
by  drop.  The  precipitated  pliospiiates  are  fil- 
trated off  and  to  the  filtrate  a  few  drops  more 
of  the  ferric  chlorid  solution  are  added.  In  case 
a  mahogany-red  color  is  produced,  it  is  probably 
due  to  the  occurrence  of  diacetic  acid.  This  color 
disappears  when  the  mixture  is  boiled,  and  it 
will  not  appear  if  the  urine  has  been  boiled  prior 
to  the  application  of  the  test. 

Ammonia 

Determination 

Formalin  Test. — Eeagents:  Formalin  (40  per 
cent,  commercial).  Alcoholic  solution  phenol- 
phthalein  (1  per  cent.)  N/10  solution  sodium 
hydrate. 

Method. — Ten  c.c.  urine  are  diluted  with  50  c.c. 
water.  To  this  are  added  2  or  3  drops  phenol- 
phthalein  (1  per  cent,  alcoholic  solution).  After 
this  the  mixture  is  neutralized  ^\dth  N/10  so- 
dium hydrate.  Following  this  5  c.c.  formalin 
(40  per  cent,  commercial),  previously  neutral- 
ized with  N/10  sodium  hydrate,  are  added  to  the 
mixture,  which  is  again  titrated  with  N/10  so- 
dium hydrate  until  a  permanent  faint  pinkish 
color  is  produced. 

Each  cubic  centimeter  of  the  decinormal  so- 
dium hydrate  used  in  the  final  titration  is  equiv- 
alent to  1  c.c.  of  decinormal  anmionia,  that  is, 
0.001704  gram  of  ammonia.  By  multipMng  the 
number  of  cubic  centimeters  of  decinormal  so- 


190        Fasting  and  UNDERNUTRmoN  iiT 

diiim  hydrate  solution  employed  in  the  final  ti- 
tration with  0.001704,  the  amount  of  ammonia 
contained  in  the  10  c.c.  of  urine  is  obtained. 

The  method  is  not  entirely  free  from  sources 
of  error,  but  is  sufficiently  reliable  for  clinical 
purposes. 

ESTIMATION  OF  SUGAR  IN  THE  BLOOD 

Epstein's  Microchemical  Test. — Blood-sugar 
determinations  are,  as  yet,  comparatively  rarely 
made  in  clinical  work.  The  reasons  of  this  are 
manifest.  The  methods  commonly  employed  are 
cumbersome  and  time-consuming;  the  amount  of 
blood  usually  withdrawn  precludes  the  frequent 
application  of  the  older  tests,  which  entail  an 
outlay  on  apparatus  and  reagents  that  cannot 
always  be  defrayed  by  the  private  physician. 
Epstein  has  adopted  the  Sahli-Gowers  hemo- 
globin colorimeter  (with  suitable  color  stand- 
ards) for  the  determination  of  sugar  in  the 
blood.  This  colorimeter  is  not  an  expensive  in- 
strument, and  it  enables  the  examiner  to  work 
with  very  small  amounts  of  the  necessary  re- 
agents and  blood.  As  a  matter  of  fact,  one  can 
with  its  aid  estimate  with  precision  the  quantity 
of  sugar  present  in  0.2  c.c.  or  even  0.1  c.c.  of 
blood. 

Eeagents:  (a)  Picric  acid,  saturated  solution; 

(b)  sodium   carbonate,    10    per   cent,    solution; 

(c)  sodium  fluorid  or  potassium  oxalate,  2  per 
cent,  solution. 


The  Treatment  of  Diabetes 


191 


iM 


Epstein's  Outfit  for  Estimating  Sugar  in  the  Blood  by 
microchemical  method. 

1.  Sahli-Growers  hemoglobinometer  stand  and  graduated  tube. 
2.  Two  standard  color  tubes,  one  (A)  suitable  for  measuring 
quantities  of  sugar  in  the  blood  ranging  from  0.05  per  cent,  to 
0.1  per  cent.;  the  other  {B)  is  adapted  to  quantities  of  sugar 
over  0.1  per  cent.;  3.  A  special  pipet  (resembling  but  larger  than 
the  hemoglobin  blood-pipet)  graduated  at  0.1  c.c.  and  0.2  c.c.  for 
collecting  and  measuring  the  blood.  4.  A  test  tube  ( ^  by  4 
inches)  graduated  at  1.0  c.c.  and  2.5  c.c.  5.  Another  test  tube 
of  similar  dimensions   (not  graduated)   suitable  for  boiling. 

(The  tubes  belonging  to  this  hemoglobinometer  are  not  all 
equally  calibrated.  With  some  the  50  per  cent,  mark  represents 
a  volume  of  1.0  c.c;  with  others,  1.0  c.c.  of  fluid  reaches  up  to 
the  43,  45,  46  or  47  per  cent.  mark.  In  all  of  the  tubes  the  error 
in  the  calibration  is  below  the  10  per  cent,  mark;  the  graduations 
above  this  mark  are  usually  correct.  By  means  of  the  standard 
1.0  c.c.  pipet  one  can  readily  determine  whether  or  not  a  given 
tube  is  properly  calibrated.  In  order  to  facilitate  a  direct  read- 
ing of  the  percentage  of  sugar  on  these  hemoglobinometer  tubes j 
it  is  essential  to  have  1.0  c.c.  of  fluid  stand  at  mark  50.  To  over- 
come a  discrepancy  (if  any  exists)  in  the  calibration  of  a  given 
tube,  one  may  put  one,  two  or  three  small  glass  beads  in  the 
bottom  of  the  tube,  of  such  size  as  to  raise  the  meniscus  of  1.0  c.c. 
of  fluid  up  to  the  50  per  cent.  mark. 


192         Fasting  an£)  Undernutrition  in 

Method, — One  or  two  drops  of  the  sodium 
fluorid  or  potassium  oxalate  solution  is  placed 
into  the  graduated  test  tube  (4).  By  means  of 
the  blood  pipet  (3),  0.2  c.c.  of  blood  is  obtained 
from  the  tip  of  the  finger  or  the  lobe  of  the  ear 
and  is  released  into  the  tube  (4)  in  which  the 
fluorid  or  oxalate  solution  is  contained.  The  pi- 
pet  is  rinsed  two  or  three  times  with  distilled 
water  and  the  washings  added  to  the  blood  in  the 
tube  (4).  After  this  distilled  water  is  permitted 
to  flow  into  the  same  tube  to  the  1.0  mark. 
When  laking  of  the  blood  has  ensued,  picric 
acid,  a  few  drops  at  a  time,  is  added  to  it  until 
the  mark  2.5  c.c.  is  reached.  As  the  picric  acid 
is  added  the  tube  is  gently  shaken.  Precipita- 
tion of  the  blood-proteins  takes  place.  The  su- 
gar, together  with  an  excess  of  picric  acid  suffi- 
cient for  the  reaction,  stays  in  solution.  The 
tube  is  finally  shaken  vigorously  while  its  mouth 
is  being  covered  with  the  finger.  Following  this 
the  contents  are  filtered  through  a  small  filter,  or, 
better  still,  centrifuged  for  one  or  two  minutes. 

One  cubic  centimeter  of  the  filtrate  or  the 
clear  supernatant  fluid  obtained  on  centrifuging 
is  withdrawn,  placed  into  the  boiling  tube  (5) 
and  heated  carefully  over  the  naked  flame.  The 
entire  contents  of  the  tube  are  boiled  until  but 
2  or  3  drops  of  the  solution  are  evaporated.  One- 
half  cubic  centimeter  of  the  10  per  cent,  sodium 
carbonate  solution  is  then  added  and  the  tube 
heated  again  until  the  contents  are  concentrated 


The  Treatment  of  Diabetes  193 

to  a  small  volume  equal  to  about  2  or  3  drops. 
The  color  of  the  fluid  changes  from  yellow  to 
deep-red  or  reddish-brown,  and  the  reaction  is 
completed.  * 

Three  or  four  drops  of  distilled  water  are  added 
and  the  tube  warmed  gently.  The  contents  are 
then  transferred  to  the  graduated  tube  (1). 
The  boiling  tube  is  rinsed  several  times  with 
water  (using  only  3  or  4  drops  at  a  time). 
The  tube  is  Avarmed  with  each  rinsing  before 
transferring  the  contents  to  the  graduated  tube. 
The  volume  is  then  made  up  to  the  mark  50. 

The  color  of  the  resulting  solution  is  com- 
pared with  that  of  the  two  standard  tubes,  A 
and  B.  If  it  is  darker  than  standard  A  (repre- 
senting 0.05  per  cent,  sugar)  and  lighter  than 
standard  B  (representing  0.1  per  cent,  sugar), 
the  first  standard  is  used  for  comparison.  In 
either  case,  the  solution  in  the  graduated  tube 
is  diluted  gradually  with  water  (as  in  hemo- 
globin estimations)  until  the  colors  match  as 
closely  as  possible. 

The  percentage  of  sugar  in  the  blood  is  then 
computed  thus:  Using  the  lighter  standard  A, 
the  figure  on  the  scale,  divided  by  1,000,  repre- 
sents the  percentage  of  sugar  in  the  blood.  For 
example,  the  tube  reads  81,  then  the  result  is 

81 
-^^0.081  per  cent. 

When  standard  B  is  used  for  comparison,  the 


194  Fasting  and  Undernutrition 

figure  on  the  scale  is  multiplied  by  2  and  di- 
vided by  1,000.  For  example,  the  tube  reads  69, 
then  the  percentage  of  sugar  is 

69X2 

=  0.138  per   cent. 


1,000 


With  the  instructions  given,  the  above  for- 
mulas may  be  used  for  direct  computation  of  the 
percentage  of  sugar  only,  when  0.2  c.c.  of  blood 
is  used  in  the  determination.  When,  however, 
only  0.1  c.c.  of  blood  is  used,  the  formulas  apply 
as  well,  but  the  value  obtained  must  be  multi- 
plied by  2. 

In  cases  in  which  a  high  sugar  content  in  the 
blood  is  suspected,  as  in  diabetes,  it  is  best  to 
use  only  0.1  c.c.  of  blood  for  the  determination. 
In  all  other  cases  0.2  c.c.  of  blood  should  be 
employed. 


NUTRITIVE    CONSTITUENTS    OF    FOOD 

The  following  tables,  taken  almost  in  their  en- 
tirety from  the  well-known  works  of  J.  Konig, 
are  given  for  general  orientation  only.  The  same 
foodstuffs,  grown  under  different  conditions  and 
surroundings,  may  greatly  differ  from  each  other 
in  their  percentage  composition.  Their  assay — 
at  the  best — can  furnish  definite  information  con- 
cerning only  those  specimens  subjected  to  exam- 
ination. Again,  in  the  milder  forms  of  diabetes, 
too  much  consideration  should  not  be  attached 
to  this  factor.  In  the  graver  t^^pes  of  the  dis- 
ease, however,  this  must  be  taken  into  due 
account. 

Nitrogenous  matter  comprises  the  proteins,  al- 
bumins, animal  and  vegetable  caseins,  gelatinous 
and  glutinous  substances. 

Nitrogenous-free  extractive  matter  (carbohy- 
drates) includes  starch,  sugar,  gums,  dextrin, 
pectin,  alcohol  and  cellulose. 

Foodstuffs,  whose  names  appear  in  italics,  are 
rich  in  sugars  and  starches.  They  must  not  be 
used  by  the  diabetic  without  permission  of  his 
physician. 


195 


196 


Fasting  and  Undeknutrition  in 


Meat  and  Fish 
Beef,  fat 

"     medium  fat 

"     lean 

Cow's  meat,  fat 

"      lean 

Veal,  fat 

"     lean 

Mutton,  fat 

half  fat 

Pork,  fat 

"     lean 

Blood 

Lung 

Heart 

Kidney 

Spleen 

Tongue 

Liver,  ox 

"      calf 

Sweetbreads  (thymus)  .  . 
Ham,  ordinary 

"      lean  (smoked) .  .  . , 
Westphalian  (smoked) . . 

Smoked  beef 

"        ox  tongue 

"       goose  breast . . . , 
Tinned  beef 

"       tongue 

American  canned  beef.  . 

Goose  liver  paste , 

Beef  paste 

Ham  paste 

Tongue  paste 

Salmon  paste , 

Lobster  paste 

Anchovies  paste 

Cervelat  sausage 

Blood  sausage 

Liver      "         

Headcheese 

Knackwurst 

Frankfurt  sausage 

Meat  sausage 

Ham  sausage 


Nitrogenous 
Matter 


17,19 
20,91 
20,78 
19,86 
20,64 
18,88 
19,86 
14,80 
17,11 
14,54 
20,25 
18,12 
14,74 
17,71 
18,01 
17,77 
14,29 
19,72 
17,66 
28,00 

25,08 
24,47 
27,10 
24,31 
21,45 
19,41 
15,35 
29,04 
14,59 
17,17 
16,88 
18,46 
18,48 
14,87 
12,33 
17,64 
11,81 
15,93 
23,10 
22,80 
11,69 
27,31 
12,87 


Fat 


29,28 
5,19 
1,50 
7,70 
1,78 
7,41 
0,82 

36,39 
5,77 

37,34 
6,81 
0,18 
4,57 
8,66 
5,11 
4,19 

17,18 
5,55 
2,39 
0,40 

8,11 
36,45 
15,35 
31,61 
31,49 
13,07 
15,14 
11,54 
33,59 
44,63 
50,88 
32,85 
36,51 
24,86 

1,59 
39,76 
11,46 
26,33 
22,80 
11,40 
39,61 
39,88 
24,43 


N-Free 
Extractive 

Matter 
(Carbohy- 
drates) 


0,48 

0,41 
0,01 
0,07 

0,05 


0,03 
1,00 
0,64 
0,15 
1,50 
0,51 
1,69 
5,47 


0,16 


1.15 

2,01 

2,67 
3,36 

0,46 
0,70 
4,05 
5,18 

25,09 
6,38 


2,25 

5,10 

12,52 


The  Treatment  of  Diabetes 


197 


Nitrogenous 
Matter 


Fat 


N-Free 
Extractive 

Matter 
(Carbohy- 
drates) 


Meat  and  Fish  {Continued) 

Trt/ffle  sausage 

Bacon,  smoked,  American 

"  "        German 

Rind  of  pork 

Calves'  feet 

Bones 

Hare 

^'enison 

Rabbit 

Horse 

Chicken,  fat 

Rooster,  young,  lean 

Duck,  wild 

Squab 

Partridge 

Fieldfare 

Turkey,  medium  fat . 

Fats 

Butter,  ordinary 

"       fine 

Ox  fat 

Lard 

Fat  tissue 

Fish 

Sole 

Codfish 

Haddock 

Perch 

Pike 

Flounder 

Ray 

Carp 

Plaice 

Sturgeon 

Trout 

Gudgeon 

Smelt 

Sea  eel 

HaUbut 

Salmon > 


13,06 
9,27 
2,60 
35,32* 
23,00* 
15,50* 
23,34 
19,77 
21,47 
21,71 
18,49 
23,32 
22,65 
22,14 
35,26 
22,19 
24,70 

1,09 
0,28 
0,44 
0,26 
2.27 

11,94 
16,23 
17,09 
18,11 
18,34 
14,03 
19,51 
21,86 
19,98 
18,00 
19,18 
17,37 
19,36 
13,57 
18,53 
15,01 


41,27 
75,75 
77,60 
3,75 
11,32 
0,50 
1,13 
1,92 
9,76 
2,55 
9,34 
3,15 
3,11 
1,00 
1,43 
1,77 
8.50 

77,48 
85,50 
98,15 
99,04 
85,43 

0,25 
0,33 
0,34 
0,44 
0,51 
0,69 
0,91 
1,09 
1,80 
1,90 
2,10 
2,68 
4,92 
5,02 
5,16 
6.42 


0,70 

0,19 
1,42 
0,75 
0,46 
1,20 
2,49 
2,33 
0.76 

1.39 


0,47t 
0.69 1 


0.45 


0.01 
0,63 


0,39 

2,85 


*Chiefly  gelatinous  matter. 
tSugar  of  milk. 
Vegetable  oils  are  pure  fats. 


198 


Fasting  and  Undernutrition  in 


Nitrogenous 
Matter 


Fat 


N-Free 
Extractive 

Matter 
(Carbohy- 
drates) 


Fish  {Continued) 

Herring 

Mackerel 

Blay 

Shad 

River  eel 

Salt  herring 

Sardelles,  salted 

Codfish,  salted 

Mackerel,  salted 

Bloater,  smoked 

Sprats 

Lamprey 

Sardines,  canned 

Caviar 

Haddock  (dried) 

Codfish  (dried) 

Oyster 

Clam 

Lobster,  fresh 

"        canned  

Crayfish,  fresh 

"        canned 

Crab,  fresh 

"     canned 

Milk  and  Dairy  Products 

Cow's  milk 

Goat's  milk 

Sheep's  milk 

Butter 

Whey 

Sour  milk 

Cream 

Kefir 

Pot  cheese 

Lean  cheese 

Half  fat  cheese 

Fat  cheese 

Cream    "     

Dutch    "     

Edam     "     

Limburger 

Emmenthal 


10,11 
19,36 
16,81 
18,76 
12,83 
18,90 
22,30 
27,07 
19,17 
21,12 
22,73 
20,18 
25,90 
30,79 

76,07 

9,04 
8,69 
14,49 
18,13 
13,63 
16,10 
15,80 
25,38 


3,41 

3,52 

6,31 

4,06 

0,85 

3,41 

3,61 

3,26 

25,04 

34,99 

27,24 

25,09 

16,28 

29,48 

24,07 

25,09 

32,42 


7,11 

8,08 

8,13 

9,45 

28,37 

16,89 

2,21 

0,36 

22,43 

8,51 

15,94 

25,59 

11,27 

15,66 

0,70 

2,04 
1,12 
1,84 
1,07 
0,36 
0,46 
1,54 
1,00 


3,65 

3,94 

6,83 

83,27 

0,23 

3,65 

26,75 

0,86 

5,04 

11,37 

23,71 

29,05 

41,22 

26,71 

30,26 

29,05 

29,67 


0,53 
1,57 


0,13 

0,98 
1,61 
0,19 
1.67 


6,44 
4,12 
0,12 
0,58 
0,21 
1,01 
0,75 
0,24 

Sugar  of  milk 
4,81 
4,39 
4,73 
3,73 
4,70 
3,50 
3,52 
2,04 
2,57 
5,40 
1,54 
2,22 
1,90 
3,72 
4,48 
3,70 
0,31 


The  Treatment  of  Diabetes 


199 


Nitrogenous 
Matter 


Fat 


N-Free 

Extractive 

Matter 
(Carbohy- 
drates) 


MUk  and  Dairy  Products  (Cont'd) 

Mayence  hand  cheese 

Hohenburg  hand  cheese 

Parmesan  cheese 

Swiss  cheese 

"SVestphalian  cheese  (half  fat) 

"       (fresh) 

Neufchatel  cheese .  .  ■  .^, 

Cheshire  cheese t 

Caraway  seed  cheese 

Eggs 

Hen's  egg,  white 

"        "    yolk 

"        "    whole  egg 

((  ((  a  n 

1  egg  50  grams 

Duck  egg 


36,33 
26,90 
41,19 
23,90 
27,49 
29,85 
17,44 
27,68 
31,61 


12,87 
16,12 
12,55 
14,49 

6,30  g. 

7,24  g. 
12,24 


5,55 
29,13 
19,52 
22,54 
26,06 
11,76 
40,80 
27,46 

7,36 


0,25 
31,39 
12,11 
15,82 

6,05  g. 

7.91  g. 
15,49 


Sugar  of  milk 
1,00 

V 

1,18 
5,04 
1,15 
7,98 
5,21 
5,89 
10,43 


0,77 
0,48 
0,55 
0,62 
0,27  g. 
0,31  g. 


200 


Fasting  and  Undernutrition  in 


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INDEX 


Aceto-acetic  acid,  see  also  Ke- 
tonosis. 

detection  of,  188. 
Acetone,  see  also  Ketonosis. 

detection  of,  186. 

detection  of  in  stools,  106. 
Acetonuria,  98,  103. 
Acid,  butyric,  116. 
Acidosis,  diabetic,  see  Ketonosis. 
Alcohol,  22,  29. 
Alkalies,  120. 
Aloin,  47. 
Ammonia,      determination     of, 

189. 
Athrepsia   infantum,    147,   160, 
161,  167. 

Bacteria,  decrease  of  intestinal, 
7. 

Beef  broth,  21,  29. 

Beers,  constituents  of,  212. 

Beta-oxybutyric    acid,    see    Ke- 
tonosis. 

Beverages,  20. 

Blood,  estimation  of  sugar  m 
the,  190. 
pressure,  diminution  of,  8. 

Body    weight,    continuous   loss 
in,  8. 

Borchardt,  103. 

Breads,    nutritive    constituents 
of,  201. 

Busquet,  59. 

Butyrone,  102. 

Carbohydrate    tolerance,    deter- 
mination of,  40,  41. 

increased,  62. 

low  or  negative,  18. 
Cardio-vaseular  disease,  20. 
Carlsbad  water,  19. 


Cecum,    functionally    diseased, 

108,  109,  110. 
Chamomile,  21. 
Charles,  60. 
Children,     periodical     vomiting 

in,  156. 
Coffee,  21. 

Diabetes  of  the  obese,  28. 
Diabetics,  female,  14. 

male,  14. 
Diacetic  acid,  detection  of,  188. 
Diaceturia,  98. 
Diarrhea,  fatty,  105. 

ketone,  105. 
Diffusion,  insufficient,  112. 
Disease,  gastro -intestinal,  156. 
Diseases,  wasting,  134,  135. 
Diuresis,  21. 
Drugs,  24. 
Duodenum,  disease  of,  21. 

Eggs,  145. 

idiosyncrasy  for,  160. 

nutritive    constituents    of, 
198. 
Enema,  46,  123. 

Failures,  apparent,  52. 

peremptory,  49. 
Fast,  inaugural,  17. 

weekly,  17,  18. 
Fasting,  9. 

a  possible  cause  of  harm,  lo. 

periods,  subsequent,  43. 

protracted,  contraindicated, 

28. 
protracted,  indications  for, 

18,  27. 
Fat  absorption,  impaired,  143. 


215 


216 


Index 


Fats,  nutritive  constituents  of, 
196. 

Feces,  fat  in,  153,  155. 

Feeding,  forced,  134. 

Ferric  chlorid  reaction,  97. 

Fish,  nutritive  constituents  of, 
196,  197. 

Flannels,  57. 

Food,  nutritive  constituents  of, 
195. 

Fruit  juices,  sugar  content  of, 
206,  207. 

Fruits,  dried,  nutritive  constit- 
uents of,  205,  206. 
fresh,     nutritive    constitu- 
ents of,  205. 

Gangrene,  18,  25. 
Gastro-intestinal     disease,     les- 
sening of,  62. 
Gelatine,  22. 

Glucosometer,  Stern's,  178. 
"Green  days,"  9. 
Guelpa,  6,  7,  8,  19. 

Headache,  21. 

Heart,  decrease  of  volume  of,  8. 

Hemoglobin,  increase  in,  8. 

Hilliger,  103. 

Home  treatment,  arguments  in 

favor  of,  11. 
Howland,  104, 
Hunger-day,     intercalation     of, 

17. 
Hunger,  disappearance  of,  7. 
Hunyadi  Janos  water,  7,  19. 
Hydremia,  20. 
Hyperpnea,  104,  105,  107. 

Infection,  18,  25. 
Ionization,  insufficient,  112. 

Jean,  163. 

Ketones,  16,  26,  97,  U2i 
in  alveolar  air,  107. 
in  intestinal  gases,  107. 
of     intestinal     production, 
101,  102,  103,  104. 


Ketonosis  (acetonuria,  acidosis, 
etc.),  18,  24,  26,  35,  49, 
97,  98,  99,  102,  105,  112. 
intestinal,   seat  of  produc- 
tion of,  108. 
intestinal,  sources  of,  116. 
intestinal,     symptoms     of, 
106. 
Kidney,  insufficiency,  18. 
Klemperer,  59. 
Konig,  195. 
Kiihn,  59. 

Lecithin,  116,  159. 
Leukocytes,  increase  in,  8. 
Liquors,  constituents  of,  211. 
Liver,  5,  10,  18,  103. 

decrease  of,  8. 
Lung  expansion,  greater,  8. 
Liithje,  58. 

Magnesium  sulphate,  19,  123. 

Marasmus,  infantile,   147.     See 
also  Athrepsia  infantum. 

Marriott,  104. 

Massage,  62. 

Masuyama,  117. 

Matter,  nitrogenous,  195. 

nitrogenous,     free     extrac- 
tive, 195. 

Meals  and  flours,  199,  200. 

Meats,     nutritive     constituents 
of,  195,  196. 

Milk  and  dairy  products,   197, 
198. 

Milk,  cow's,  character  and  pro- 
portion of  fatty  acids  in, 
151. 
mother's,  character  and 
proportion  of  fatty  acids 
in,  151. 
physical   characters  of  the 

fat  of  cow's,  150. 
physical   characters  of  the 
fat  of  mother's,  150. 

Moritz,  177. 

Morphine,  25. 

Moss6,  113. 

Mueller,  117. 


Index 


21? 


Naunyn,  9. 
V.  Noorden,  112,  114. 
Nurse,  the,  12,  13,  14. 
Nuts,  nutritive  constituents  of, 
207. 

Oatmeal  cure,  112,  113,  114. 

Obeserskv,  117. 

Obesity,  18. 

Oil.  castor,  7,  19,  20,  47,  123. 

Oil,  cod-liver,  161. 

Olein,  lie. 

Overfeeding.  134. 

Pain,  reduction  of  neuritie  and 
angiosclerotic,  62. 

Pains,    disappearance    of    joint 
and  muscular,  8. 

Palmitin.  116. 

Pancreas,    diminished    activity, 
28. 

Perspiration,  decline  of,  8. 
profuse,  57. 

Phenolphthalein,  47. 

Potatoes,  40,  41. 

Proprione.  101. 

Proteins,  10. 

Pulse,  firmness  of,  8. 

Purging,  19. 

Rest,  56. 

Red  cells,  increase  in,  8. 

Schmidt,  153. 
Schwartz,  115. 
Sodium  sulphate,  19,  123. 
Sparers  of  body  tissue,  21. 
Ssoborovr,  117. 
Starches,  10. 
Stearin.  116. 

St«rn.  133,  155,  178.  182. 
Stimulants,     alkaloidal.     nutri- 
tive constituents  of.  199. 
Stomach,  disease  of.  21. 
Strasburger,  153. 
Sugar  in  blood,  12. 

estimation  of.  190. 

in  urine,  12,  16,  26.  29,  54. 
61. 

in  urine,  detection  of,  171. 


Sugar    in    urine,   determination 

of,  176. 
Tea,  7,  20,  21,  29. 
Temperature,       external,       and 
course  of  glycosuria,  56,  57, 
58,  59.  60,  61,  62. 
Test,    Epstein's    microchemical, 
190. 
Fehling's,  181. 
fermentation,  176. 
ferric  chlorid,  188. 
formalin  for  ammonia,  189. 
Gerhardt's.   188. 
Lieben's,  188. 
Xylander's,  173. 
sodium  nitroprusside,  186. 
sodium        nitroprusside 
(Niece's     improvement), 
187. 
Thirst,  reduction  of,  7. 

IJffehaann,  153. 

Underfed,  yolk  cure  in  treat- 
ment of  the,  133. 
Undernutrition,  graded  dieta- 
ries, 29,  30,  31,  32,  33. 
34.  35,  36,  37,  3  ,  39,  40. 
41,  42,  43. 
immediately      following 

fasting,  27.* 
movement   of    bowels    dur- 
ing, 46,  47. 
in  diabetes,  9,  29. 
rest  during,  47. 
water  during.  46. 
Urine,  assay  of,  171. 

sugar  in,  12,  16,  26,  29,  54, 
61. 

Valerone,  102. 
Vegetables,  10. 

and   salads,   nutritive  con- 
stituents   of,     202,    203, 
204. 
Volhard,  155. 

Walking,  63. 
Waters,  aerated,  46. 
Wines,    fruit,    constituents    of, 
210. 


218  iNDElt 

Wines,  red,  constituents  of,  209.  Yolk,  cure,  116,  133,  136,  143, 

sparkling,   constituents   of,  146. 

210.  diastatic   ferment  in,    117, 

sweet,  constituents  of,  211.  159. 

white,  constituents  of,  208,  Yolks,  29,   116,   137,   138,   139, 

209.  140,  142,  158,  160. 


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A 

1    °«   HI 

Anne 

X 

1  1 1  1 1  1 V 

^#  m 

C28    n264)    50M 

stem 


HC660 

St4 

1916 


Fasting  and  undernutrition  in 


1 


OCT  •  .       / 


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